PR or E R rv og sº scIEN T E f A R A TEXTBOOK OF Surgery for Nurses Second Edition—Illustrafed EDWARD S. STAFFORD, B.A., M.D., F.A.C.S. Associate Professor of Surgery, The Johns Hopkins University; Surgeon, The Johns Hopkins Hospital; Lecturer in General Surgery, The Johns Hopkins Hospital School of Nursing DORIS DILLER, B.A., R.N. Associate Professor of Nursing and Director of the Cancer Control Project, Skidmore College Department of Nursing, New York City; formerly Instructor and Supervisor, Surgical Nursing, The Johns Hopkins Hospital School of Nursing W. B. SA UN D E R S C O M P A NY Philadelphia - London - 1954 20 Nurses Library RV) a 4. | | § 4.4– ce, 2 % 3. •r Copyright, 1954, by W. B. Saunders Company Copyright, 1947, by W. B. Saunders Company Copyright under the International Copyright Union All Rights Reserved. This book is protected by copyright. No part of it may be duplicated or reproduced in any manner without written permission from the publisher. Made in United States of America Press of W. B. Saunders Company, Philadelphia Library of Congress Catalog Card Number: 54-5309 Nºvº Alb Ovºteſ. PREFACE TO 5, 12, 3 } THE SECOND EDITION 377 2,2' SINCE the publication of the first edition, significant advances have been achieved in numerous areas in surgery. Among these are the development of cardiac surgery, the increasing scope of thoracic surgery, improved preoperative and postoperative care of patients, widespread acceptance of the recovery room method, and heightened emphasis on rehabilitation. In order to make room for adequate presentation of these and many other subjects, the authors have omitted the chapters on anesthesia and operat- ing room technic; these last are taught in separate courses in most Schools of nursing and good texts are available. The nursing care of surgical patients is stressed, and the reader will find that the plan for total care in considerable detail is given for each important surgical problem. Some of the original illustrations have been altered, and some new illustrations added in order to increase understanding. A brief summary has been put at the end of most of the chap- ters for the purpose of developing an attitude toward the subject matter. The summary is followed by a vocabulary review; in this, the words are selected as much for the purpose of bringing into mind again a particular detail as for the difficulty in spelling. Finally, there is a list of suggested readings, chosen chiefly from the current literature, affording an opportunity to the student who wishes more knowledge in any given subject. For, as the authors stated in the preface to the first edition, the more the nurse knows about surgery, about the aims of the surgeon, and about what has been accomplished in the operating room, the better will she be able to care for the surgical patient. It will be noted that the subject matter of the various units usually represents a special field of surgery, and often one which * a separate service in the highly organized modern hospital. Throughout the text the reader will note many references to the excellent textbook on medical nursing by Brown, in which iii iv PREFACE TO THE SECOND EDITION can be found a wealth of nursing detail for patient care in many situations which are entirely applicable to surgical patients, such as oxygen therapy, care in a respirator, and so on. All page refer- ences are to Brown, Amy Frances: Medical Nursing. 2d Ed. Phila- delphia, W. B. Saunders Co., 1952. Almost all of the new illustrations are the work of Elinor Wid- mont Bodian. The chapters on plastic surgery, burns and the breast have been revised by Dr. William Gray Watson of Pittsburgh, Pennsylvania, the chapter on the thyroid and parathyroids by Dr. Robert Lee Payne, Jr., of Norfolk, Virginia, the chapter on ophthalmology by Dr. William Wickham Taylor of Norfolk, Virginia, the chap. ter on otolaryngology by Dr. Dudley C. Babb of Baltimore, and the chapters on gynecology by Dr. C. Bernard Brack of Baltimore, each of whom was the original author of the chapters mentioned. Dr. Frank J. Otenasek of Baltimore has revised the chapters on neurosurgery. As before, the authors gratefully acknowledge the helpfulness of the numerous members of the surgical and nursing staffs of The Johns Hopkins Hospital whose advice and aid have been sought. EDWARD S. STAFFORD DORIS DILLER Baltimore, Maryland January, 1954 CONTENTS Unit I. THE FUNDAMENTALS OF SURGICAL NURSING Chapter 1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l The Nurse in Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Chapter 2. WOUNDS AND HEALING . . . . . . . . . . . . . . . . . . . . . . 6 Wounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Healing of Wounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Treatment of Wounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Nursing Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Chapter 3. SURGICAL INFECTIONS . . . . . . . . . . . . . . . . . . . . . . . 22 Nursing Care of Surgical Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ; . . . . . . . . . . 36 Chapter 4. NEOPLASTIC DISEASE . . . . . . . . . . . . . . . . . . . . . . . . 36 Nomenclature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Treatment of Neoplastic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Nursing the Patient with Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 vi CONTENTS Chapter 5. NUTRITION AND WATER BALANCE . . . . . . . . . . . . . . 48 Maintenance of Metabolic Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Chapter 6. HEMORRHAGE AND SHOCK . . . . . . . . . . . . . . . . . . . . 57 Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Chapter 7, PREPARING THE PATIENT FOR OPERATION . . . . . . . 70 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8] Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8] Chapter 8. POSTOPERATIVE NURSING CARE . . . . . . . . . . . . . . . . 81 Recovery Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Routine Care During Recovery from Anesthesia . . . . . . . . . . . . . . . . . 84 Return to Ward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Immediate Postoperative Complications . . . . . . . . . . . . . . . . . . . . . . . . . 92 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Chapter 9. CONVALESCENT NURSING CARE AND REHABILITA- TION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 CONTENTS vii Unit II. NURSING IN THORACIC SURGERY Chapter 10. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 Chapter 11. THORACIC INJURIES . . . . . . . . . . . . . . . . . . . . . . . . 106 Blunt Force Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Penetrating Wounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Diaphragmatic Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Nursing Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 10 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 11 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 || 1 Chapter 12. SUPPURATIVE DISEASE OF THE LUNG AND PLEURA 112 Lung Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Bronchiectasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Empyema Thoracis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Chapter 13. SURGERY OF PULMONARY TUBERCULOSIs . . . . . . . 130 Collapse Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Tuberculous Empyema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Tuberculosis of the Ribs and Sternum . . . . . . . . . . . . . . . . . . . . . . . . . . 142 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Chapter 14. NEOPLASTIC DISEASE of THE RESPIRATORY OR- GANS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Primary Neoplasms of the Bronchi and Lungs . . . . . . . . . . . . . . . . . . . . 143 Neoplasms of the Mediastinum and Chest Wall . . . . . . . . . . . . . . . . . . . 147 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148 Suggested Reading viii CONTENTS Unit III. NURSING IN VASCULAR SURGERY Chapter 15. CIRCULATORY DISTURBANCES: THROMBOSIS; EM- BOLISM; GANGRENE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 Thrombosis . . . . . . . . . . . . . . . . . . . . ‘. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Embolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Gangrene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Phlegmasia Alba Dolens; Lymphedema . . . . . . . . . . . . . . . . . . . . . . . . . . 156 Vasospasm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Chapter 16. PERIPHERAL VASCULAR DISEASE . . . . . . . . . . . . . . 160 Aneurysm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160 Varicose Veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162 Phlebitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Arteriosclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Thromboangiitis Obliterans (Buerger's Disease) . . . . . . . . . . . . . . . . . 167 Raynaud's Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Scalenus Anticus Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l68 Nursing Care in Circulatory Disturbances . . . . . . . . . . . . . . . . . . . . . . . 168 Surgical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Amputations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170 Sympathectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Chapter 17. SURGERY OF THE HEART AND GREAT VESSELS . . . 177 Conditions Requiring Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . 178 Nursing Care in Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 Chapter 18. DISEASES OF THE BLOOD-FORMING Tissues AND SPLEEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196 CONTENTS ix Unit IV. NURSING IN SURGERY OF THE ALIMENTARY TRACT Chapter 19. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 Chapter 20. NURSING IN ORAL SURGERY . . . . . . . . . . . . . . . . . . 200 Clefts of Lip and Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200 Tonguetie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Infections of the Mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Salivary Gland Disturbances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206 Tumors of the Mouth, Tongue and Jaw . . . . . . . . . . . . . . . . . . . . . . . . . 207 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 Chapter 21. NURSING IN SURGERY OF THE ESOPHAGUs . . . . . . . 213 Wounds of the Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 Benign Esophageal Stricture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 Tracheoesophageal Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 ! Esophageal Diverticula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219 Achalasia of the Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 Tumors of the Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 Chapter 22. NURSING IN ABDOMINAL SURGERY . . . . . . . . . . . . 224 Abdominal Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228 Abdominal Incisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230 Postoperative Nursing Care of Laparotomy Patients . . . . . . . . . . . . . . 233 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238 Chapter 23. PERITONITIS AND ILEUs . . . . . . . . . . . . . . . . . . . . . 239 Peritonitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 Pleus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246 X CONTENTS Chapter 24. NURSING IN GASTRIC SURGERY . . . . . s a s • e e s w = s e 246 Pyloric Stenosis in Infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248 Ulcers of the Stomach and Duodenum . . . . . . . . . . . . . . . . . . . . . . . . . . 250 Neoplasms of the Stomach and Duodenum . . . . . . . . . . . . . . . . . . . . . . . 259 Operations on the Stomach and Duodenum . . . . . . . . . . . . . . . . . . . . . . 261 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272 Chapter 25. SURGERY OF THE LIVER, BILIARY TRACT, AND PAN- CREAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272 Jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274 Diseases of the Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275 Cholecystitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276 Cholelithiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278 Neoplastic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279 Diagnosis of Biliary Tract Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279 Operations on the Gallbladder and Biliary Ducts . . . . . . . . . . . . . . . . . 281 Diseases of the Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286 Suggested Reading Chapter 26. SURGERY OF THE SMALL INTESTINE AND APPENDIx 287 The Ileum and Jejunum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 Operations on the Small Intestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289 Mechanical Ileus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290 The Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294 Meckel's Diverticulum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299 Suggested . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299 Chapter 27. NURSING IN Colon SURGERY . . . . . . . . . . . . . . . . 300 Inflammatory Lesions of the Colon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 Other Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304 Intussusception ........................................... 305 Megacolon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306 Volvulus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306 Polyposis of the Colon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306 Cancer of the Colon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307 CONTENTS xi Preoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307 Operations on the Large Intestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309 Nursing Care after Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.11 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.18 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.18 Chapter 28. NURSING IN PROCTOLOGIC SURGERY . . . . . . . . . . . 319 Fecal Impaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320 Fissure in Ano . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321 Anal Pruritus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321 Hemorrhoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321 Ischiorectal Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322 Fistula in Ano . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323 Rectal Incontinence; Imperforate Anus . . . . . . . . . . . . . . . . . . . . . . . . . . 324 Lymphopathia Venerea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324 Nursing Care in Rectal Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325 Neoplastic Disease of the Rectum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330 Unit V. SURGERY OF THE URINARY TRACT Chapter 29. NURSING IN UROLOGIC SURGERY . . . . . . . . . . . . . 331 Methods of Examining the Urinary Tract . . . . . . . . . . . . . . . . . . . . . . . . 332 Congenital Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339 Diseases of the Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339 Diseases of the Kidney and Ureter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350 Unit VI. SURGERY OF THE INTEGUMENTARY SYSTEM Chapter 30. NURSING IN PLASTIC SURGERY . . . . . . . . . . . . . . . . 353 General Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354 Skin Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357 xii CONTENTS The Treatment of Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363 Maxillo-facial Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363 Cosmetic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364 Mammaplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365 Nursing Care in Plastic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368 Chapter 31. THE CARE OF BURNS . . . . . . . . . . . . . . .. . . . . . . . . 369 The Initial Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370 The Supporting Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373 Recovery Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375 Burns Resulting from Atomic Energy . . . . . . . . . . . . . . . . . . . . . . . . . . . 375 Nursing Care of Burned Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377 Chapter 32. SURGERY OF THE BREAST . . . . . . . . . . . . . . . . . . . . 378 Diseases of the Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380 Radical Mastectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385 Radiation Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386 Hormones and Breast Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386 Metastases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387 Nursing Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387 Summary . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390 Unit VII. DISEASES DUE TO ALLERGY Chapter 33. THE ROLE OF SURGERY IN ALLERGIC DISEASE. . . 391 Unit VIII. SURGERY OF THE ENDOCRINE GLANDS Chapter 34. SURGERY OF THE THYROID AND PARATHYROID GLANDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394 CONTENTS xiii The Thyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394 The Parathyroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406 Chapter 35. SURGERY OF THE PITUITARY, THYMUs, PANCREAs, AND ADRENALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406 The Pituitary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406 The Thymus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407 The Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407 The Adrenals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409 Unit IX. NURSING IN NEUROLOGIC SURGERY Chapter 36. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 Chapter 37. INTRACRANIAL INJURIES . . . . . . . . . . . . . . . . . . . . 414 Results of Intracranial Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415 Treatment of Intracranial Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.18 Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421 Chapter 38. BRAIN TUMoRS (INCLUDING BRAIN ABSCESS, TUBER- CULOMA, SUBDURAL, HEMATOMA, AND ANEURYSMS) . . . 422 Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422 Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424 Nursing Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431 Brain 'Abscess; Tuberculoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435 Subdural Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436 Intracranial Aneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437 xiv CONTENTS Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437 Chapter 39. SURGERY OF THE CRANIAL NERVES . . . . . . . . . . . . 438 Trigeminal Neuralgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439 Glossopharyngeal Neuralgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 440 Ménière's Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441 Spasmodic Torticollis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442 Chapter 40. SURGERY OF THE SPINAL CORD . . . . . . . . . . . . . . . 443 Diagnosis of Spinal Cord Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443 Herniated Nucleus Pulposus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444 Tumors of the Spinal Cord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445 Laminectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447 Unit X. SURGERY OF THE EYE, EAR, NOSE AND THROAT Chapter 41. NURSING IN OPHTHALMoLOGY . . . . . . . . . . . . . . . 449 Methods of Examining the Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453 Refraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453 Office Nursing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454 Injuries and Their Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455 Piseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459 Nursing Care in Ophthalmology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478 Chapter 42. NURSING IN OTOLARYNGoLocy . . . . . . . . . . . . . . . 478 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478 CONTENTS XV The Nose and the Paranasal Sinuses . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481 The Pharynx and the Larynx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 492 The Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508 Unit XI. NURSING IN ORTHOPEDIC SURGERY Chapter 43. DEFORMITIES OF THE BONES, Joints AND MUSCLES 509 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509 Congenital and Acquired Deformities . . . . . . . . . . . . . . . . . . . . . . . , 514 The Hospital School . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 522 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523 Chapter 44. MUSCULOSKELETAL INJURIES . . . . . . . . . . . . . . . . 524 Injuries to Joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525 Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527 Spinal Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533 Nursing Care in Musculoskeletal Injuries . . . . . . . . . . . . * e º e º & s = * * * * 535 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 543 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 544 Chapter 45. INFLAMMATORY, INFECTIOUs, AND NEOPLASTIC DISEASES OF THE MUSCULOSKELETAL SYSTEM . . . . . . 544 Tenosynovitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545 Dupuytren's Contracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 546 Bursitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 546 Myositis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . … 546 Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 546 Osteomyelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547 Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549 Neoplastic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 550 Ganglion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 554 xvi CONTENTS Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 554 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 554 Chapter 46. ABDOMINAL HERNIA . . . . . . . . . . . . . . . . . . . . . . . . 554 Inguinal Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 556 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ' ' ' ' ' ' ' 560 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 560 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 560 Unit XII. NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS Chapter 47. SURGERY OF THE MALE GENITAL ORGANs . . . . . . 561 Congenital and Acquired Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . 563 Injuries of the Male Genitalia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 568 Infections of the Male Genitalia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569 Neoplastic Disease of the Male Genitalia . . . . . . . . . . . . . . . . . . . . . . . . 570 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579 Chapter 48. GYNECOLOGY: INTRODUCTION . . . . . . . . . . . . . . . . 580 Anatomy and Physiology of the Female Genital Tract . . . . . . . . . . . . 580 Pelvic Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 587 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 591 Vocabulary Review Chapter 49. INFECTIONS OF THE FEMALE GENITAL TRACT ... 592 Gonorrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 592 Gonorrheal Vulvovaginitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 596 Cervicitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 596 Puerperal and Postabortal Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . 597 Tuberculosis of the Genitalia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 599 Granuloma Inguinale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600 Lymphogranuloma Venereum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 600 Special Nursing Procedures in Pelvic Inflammatory Disease . . . . . . . 601 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 603 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 603 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 603 CONTENTS xvii Chapter 50. CONGENITAL DEFORMITIES; STERILITY; DISORDERS DUE TO PREGNANCY . . . . . . . . . . . . . . . . . . . . . . . . . . . . 604 Congenital Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 604 Sterility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 605 Relaxation and Malposition of the Female Genitalia . . . . . . . . . . . . . 608 Extra-uterine Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613 Chapter 51. NEOPLASTIC DISEASE OF THE FEMALE GENITAL TRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613 Benign Tumors of the Vulva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613 Carcinoma of the Vulva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614 Benign Tumors of the Cervix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615 Myomata Uteri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615 Carcinoma of the Cervix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 618 Carcinoma of the Body of the Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . 622 Sarcoma of the Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623 Ovarian Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623 Ovarian Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 624 Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627 Unit XIII. COMMUNICABLE DISEASE Chapter 52. CoMMUNICABLE DISEASES IN SURGERY . . . . . . . . . 629 Rabies (Hydrophobia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 630 Tetanus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 630 Gas Bacillus Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 633 Skin Diphtheria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 634 Other Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 634 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635 Vocabulary Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635 Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 635 Unif I. THE FUNDAMENTALS OF SURGICAL NURSING CHAPTER 1 Introduction The word surgery is a combination of the Greek words for hand and work. In ancient times physicians scorned to use their hands for work; hence such manual tasks as were thought necessary in the treatment of a patient were carried out by less exalted indi- viduals. Much of the surgery of antiquity was performed by barbers; indeed the barber's pole is in reality the surgeon's sign- post, as it symbolizes a leg encased in a bloodstained bandage. Surgery is one of the special subdivisions of the healing art, and its aims include the relief of pain, the cure of disease, the restora- tion of function to the crippled limb or damaged organ, and the Social and economic rehabilitation of the individual. The practice of surgery as we know it today owes its existence to fundamental scientific discoveries of the past century. One of these was the introduction of anesthesia. Ether was used by Crawford Long of Georgia, in 1842, but W. T. Morton of Boston, l 2 THE FUNDAMENTALS () F SURGICAL NURSING in 1846, really demonstrated the usefulness of this drug. It is difficult today to imagine the agony of the patient during a sur- gical operation performed without anesthesia, or to realize the obstacles confronting the surgeon in operating upon the scream- ing, struggling victim. Another fundamental advance was the application to surgery of the knowledge of bacteria. Following the discovery by Pasteur that putrefaction is due to bacterial contamination, Lister, a British surgeon, realized that suppuration must be a similar process. In 1865 he described a method by which he was able to control bacterial contamination, with the result that wounds did not suppurate. Before that time, inſection of wounds was thought essential to healing; in fact, pus was considered laudable and Surgeons sought to encourage its formation, even introducing into wounds foreign bodies of various sorts (Setons) in order to make suppuration certain. In contemplating surgery today it is hard to realize that less than one hundred years ago surgeons dared not enter the abdominal cavity, the chest, or the skull, and that even minor operations were followed by grave infection, with prolongation of convalescence or even death. More recently, the application to surgery of many new sci- entific discoveries has opened new fields, and has made modern surgery amazingly safe for the patient. Antisepsis and Asepsis. During the evolution of modern sur- gery, certain principles were developed which are essential to its success. One of these is the control of infection. Lord Lister intro- duced a method which attempted to kill all bacteria that might gain entrance to the wound. This technic was called antisepsis (against inſection), and consisted in the use of chemical agents which could destroy bacteria. The original method called for the treatment of the patient's skin, the Operator's hands, the instru- ments, and the Sponges with a solution of carbolic acid; in addi- tion, an overhead spray diffused droplets of carbolic acid over operative field and operator. Although the success of this treat. ment in controlling infection was great, it was not complete; also the carbolic spray was uncomfortable and highly irritating, fre- quently burning the skin of both patient and surgeon. Neverthe. less, a beginning had been made, from which it was a logical step to the adoption of aseptic technic. Asepsis (without infection) means the Prevention of infection by complete exclusion of bad. teria. This method resulted from the contributions of numerous INTRODUCTION 3 fi º 2 § º & º º - j ñiº;º §szºº ºf Yºº iš: 2- 2:3. S N a sº - º S Vº § Š § Gº º 2- § º |/ s RS Sº === x= FIGURE 1. Aseptic operating room technic. White surfaces designate what is clean, and the shaded surfaces designate the unsterile or din typerson- nel and equipment. The floor and walls, although unsterile, are not shaded. surgeons, notably Lawson Tait in Great Britain, Halsted in the United States, and von Bergmann in Germany. Absolute asepsis, however, is an ideal Condition, attained with difficulty. To understand this fact it is necessary to consider the Sources of bacterial Contamination during a surgical procedure. Disease-producing (pathogenic) bacteria are ubiquitous. They may be found on the skin of the patient and on that of the sur- geon and his associates. The nose, mouth, and throat of every one are contaminated, as are also the internal surfaces of the respira- tory and gastrointestinal organs. Bacteria abound in dust and float in the air; therefore every object that is exposed, be it furniture, clothing, instruments, or dressings, may be Contami- nated. Since this is so, it is obvious that asepsis is not static, that an object made sterile (bacteria free) may not remain so. Operative Trauma; Hemostasis. Another essential principle is the avoidance of undue trauma. Every surgical operation must be considered an injury to the body; an operative incision is better planned than an accidental one, but both result in wounds which must heal. In order to minimize damage, tissues and organs must be handled carefully and only such manipulation and dis- 4 THE FUNDAMENTALS OF SURGICAL NURSING section carried out as are necessary for the success of the opera- tion. Speed in operating, with resultant roughness, is no longer as important as in the preanesthetic days. Adherence to this principle of minimizing trauma aids also in preserving the bio- logic assets of the patient. Where possible, the functions of muscles, nerves, and organs must be retained. Preservation of the patient's store of blood by the most rigid hemostasis (arrest of escape of blood) not only saves life, but also shortens convales. cence and reduces complications. Mental Aspects. Another important consideration is the atti- tude and mental condition of the patient. A fearful or unneces- sarily frightened patient undergoes surgery with an added handi- cap. Kind, thoughtful treatment and reassurance are essential, for without them permanent damage to the personality may result. THE NURSE IN SURGERY The role of the nurse in surgery is not secondary to that of the surgeon; it is equally important. The success of the operation, in fact the very life of the patient, depends upon the reliability of all those engaged in surgical nursing. Without complete honesty, without conscientious attention to details, there will be no asepsis. Following operation patients are often critically ill; complications arise which need immediate treatment, and these must be detected by the constant care and watchfulness of the Ill IITS6. The importance of the personal relation between patient and nurse must be emphasized. Every patient finds himself in a new environment, separated from his home, his relatives, and his routine of life; in addition, he may be—and often is—in actual physical discomfort. It is not surprising, therefore, that such a patient needs reassurance; his comfort and the maintenance or development of his morale depend chiefly upon the nurse. The confidence of the patient is gained by a sincere interest in his fam- ily, his occupation, his personal problems, by attempting to mold the hospital routine as far as possible to conform with his mode of life, and by reassuring him concerning his progress. These matters are also the responsibility of the surgeon, but the nurse of necessity spends far more time with the patient. Reassurance is doubly important for a patient who will find it necessary to change his way of living as a result of his injury or illness, as, for INTRODUCTION 5 example, a patient who has had a limb amputated. There is much that scientists do not understand about life, but it has often been observed that the patient's will to live seems to play a large part in the outcome of an illness. The encouragement of this will to live is as important a contribution to the welfare of the patient as is food, medicine, or any part of the nursing care. Total Care. The responsibilities of the physician and of the nurse do not cease when the patient is pronounced “out of dan- ger,” nor when the incision is healed, nor even when the patient leaves the hospital. Home care, follow-up visits in the home or clinic, programs of instruction, and whatever other nursing meas- ures are needed to ensure the fullest possible rehabilitation of the patient are all essential parts of the idea of total care. In its broadest sense, this concept also includes measures directed toward the prevention of injury and disease. Since the surgeon and the nurse are working together for the welfare of the patient, they must enjoy mutual confidence and respect. The nurse will carry out the surgeon's instructions, but she will do it better if she understands the surgeon's purpose; he will do well, therefore, to keep the nurse fully informed. Simi- larly, the patient's welfare is the surgeon's concern, and the patient will profit from intelligent, reliable reports from the nurse to the surgeon. Here, as in all of life, there is no substitute for hard work, honesty and loyalty. SUMMARY Careful study of every aspect of each patient is necessary in order to suit the treatment to his needs and to minimize the risk. It is still true that every surgical procedure is hazardous, though today that hazard is in most instances slight. Although there have been many recent advances in surgery, there still remains much that is imperfect or undeveloped, and constant effort must be made to find new facts, new principles, and new methods, as well as to reexamine the old. The aim of surgery is the rehabilita- tion of the patient; every activity of surgical nursing should be so oriented. VOCABULARY REVIEW antisepsis pathogenic hemostasis asepsis sterile rehabilitation suppuration travlºma 6 THE FUNDAMENTALS OF SURGICAL NURSING SUGGESTED READING 1. Gregg, Dorothy: Anxiety—A Factor in Nursing Care. Am. J. Nursing, 52: 1863–1365 (Nov.) 1952. 2. Keeton, Robert W.: Nutrition and Appetite Training During Illness. J.A.M.A., 151:253–260 (Jan. 24) 1953. 3. Lais, Barbara Brice: Does Your Voice Defeat You? Am. J. Nursing, 51:322 (May) 1951. 4. Simmons, Leo W.: The Manipulation of Human Resources in Nursing Care. Am. J. Nursing, 51:452–455 (July) 1951. . Van Schoick, Mildred R.: Emotional Factors in Surgical Nursing. Am. J. Nursing, 46:451–454 (August) 1946. 5 CHAPTER 2 Wounds and Healing WOUNDS A wound is the forcible solution of the continuity of tissue. It is considered open iſ the skin has been divided, closed if the con- tinuity of the skin is uninterrupted. Wounds are commonly pro- duced in a variety of ways, so many, in fact, that it is best to classiſy them according to the injury produced, since that is what determines the manner of healing and the form of treatment, al- though Certain exceptions to this general statement will be noted later. Open Wounds Abrasions. In an abrasion the injury is confined to the most superficial layer of the skin (epidermis). It is a common wound of everyday activity, and probably no one has failed to “bark his knuckles” or “scrape his shins.” An abrasion is usually caused by a glancing blow, and may be trivial; but often a considerable skin area is exposed to the abrasive agent, as may happen when a person is hurled to the street by collision with a moving automo- bile. A varying amount of the epidermis may be scraped off; frequently the defects thus produced are filled with small par. ticles of dirt or other foreign material. These particles, if not WOUNDS AND HEALING 7 FIGURE 2, Laceration of hand. removed, retard healing, and may result in unsightly tattoo marks. Incised Wounds; Lacerated Wounds. These may be considered together, since division of the skin with exposure or possible in- jury of the underlying structures is common to both. Incised wounds are made by sharp-edged objects, such as knives, glass, or tin cans; lacerations result from the application of a force which tears or splits the skin. Operative incisions are incised wounds, differing from accidental incised wounds chiefly in their purpose and in the conditions under which they are made. The incised wound has regular edges; those of the laceration are usually uneven, with more destruction of tissue. Avulsed Wounds. An avulsed wound is made by sharp or blunt objects; its characteristic is the loss of tissue. This type of wound is caused by contact with a rapidly moving object, as, for exam- ple, a bomb fragment. In an extensive avulsion there may be actual loss of portions of muscles, tendons, nerves and blood ves- sels, in addition to the overlying skin. Penetrating (Puncture) Wounds. These follow the introduction into the body of a pointed object, e.g., needle, splinter, nail, ice pick, or of a small object traveling at high speed (e.g., a bullet). These wounds are characterized by a small surface opening which gives no clue to the depth or extent of the underlying damage. In this type of wound the possibility of perforation of underlying organs is great; it is in these wounds also that anaerobic bacteria may grow, since the small surface opening quickly seals over and thus prevents the oxygen of the air from reaching the depths of the wound. 8 THE FUNDAMENTALS OF SURGICAL NURSING (º, º ſ * =S ~ § sº º U \s FIGURE 4. Contusion. WOUNDS AND HEALING 9 Closed Wounds Blisters. The familiar blister is a simple superficial closed wound. Following chemical, thermal, or frictional irritation of the skin, the damaged epidermis becomes raised and separated from the deeper layer by an outpouring of serum. If the Con- tinuity of the superficial epidermis is broken, the wound then becomes an open one. Confusions. A blow of adequate force on the skin produces a contusion (bruise), and swelling and discoloration result from the outpouring of serum and blood which follows this injury to the subcutaneous tissues. A collection of blood (hematoma) may form in this way, but more often the extravasated blood is spread diffusely through the tissues in the region of the injury. Other Varieties of Closed Wounds. Sprains, which result when the supporting ligaments of joints are torn, dislocations of joints, and simple fractures are all closed wounds. Under a va- riety of circumstances force directed against the chest or the abdomen produces laceration or perforation of the internal organs. That a severe crushing injury may do so is readily under- standable; but internal injury following a relatively light blow, without any damage to the overlying skin, is surprisingly Com- mon. These closed wounds are known as subcutaneous injuries to the chest and abdomen. HEALING OF WOUNDS The healing of a wound depends upon the ability of the in- jured tissues to repair themselves. This in turn depends upon the exact nature of the injured tissues, as well as upon certain more general features, such as the presence of pathogenic bac- teria, the physical condition of the patient, his state of nutrition, the location of the wound, and the method of treatment. The Process of Repair. Immediately following injury to the skin there is bleeding from divided capillaries or larger vessels and outpouring of tissue fluid from opened lymphatics and inter- cellular spaces. Ordinarily the bleeding ceases in from two to six minutes as a result of clotting of the blood; if not dislodged, this coagulum protects the surface of the wound. Within a few hours white cells (leukocytes) from the blood and wandering connective tissue cells begin to move into the blood clot. At the same time the injured capillaries about the wound begin to grow, gradually forming new capillary loops which push their 10 THE FUNDAMENTALS OF SURGICAL NURSING £º ... Nº º Ficure 5. Primary healing. The blood clot is replaced first by granulation tissue and finally by scar tissue. way into the blood clot. This newly formed tissue, composed of capillaries, leukocytes, and wandering cells, has a red velvety or granular appearance, and is known as granulation tissue. It gradually takes the place of the blood clot; much of this is di- gested and removed, the remainder serves as protection to the external surface of the wound in the form of a scab. At the same time the epithelial cells on the skin surface begin to grow more rapidly and to divide with increased frequency. Spreading into the wound on its surface from all sides, these cells seek to restore the epithelial continuity. When the granulation tissue has filled the defect and the surface is epithelialized, the crust or scab is shed. At this stage the wound appears healed; however, healing is not complete until the granulation tissue organizes into scar tissue. The whole process of repair occupies two weeks or more, depending upon the size of the wound and many other factors. Primary Healing. Under favorable conditions primary union (healing by first intention) occurs. Iſ the edges of an incised wound in a healthy person are promptly and accurately ap- proximated, iſ bacterial contamination has been slight and is held to a minimum, if there is no foreign material in the wound, and if the wound is protected from movement or other trauma, healing is prompt. Approximation of the wound edges minimizes not only the defect to be filled with blood clot and the gap in the tissues, but also the opportunity for bacteria to enter the depths of the wound. There will be only as much granulation tissue as is necessary to occupy this small space; consequently there will be only a narrow scar. During the healing process there will be less inflammation, less pain, and no discharge of secretion or pus. Y WOUNDS AND HEALING 1 I ę Š. £3. § § § gºš § º g §§ Fº § & ſº &gº-> #3% Epitheliall- LBuddin ſº $ capillaiee º **** Q 49 Leukocytes \\ | g ºl \S$. Ö4 ºl FIGURE 6. Secondary healing. Exuberant granulation tissue and slow epithelial ization lead to excessive scar formation. Secondary Healing. The tissues of the human body have a mar- velous capacity for repairing wounds under the most adverse circumstances. Secondary union (healing by second intention) differs from primary union only in degree; in each, the same fun- damental repair process is at work. Wounds in which the tissue edges are widely separated, which may be due either to lack of approximation or to such loss of substance as to prevent approxi- mation, heal slowly. There is a large defect, and consequently a large amount of granulation tissue, resulting in a large scar. Secondary healing is usually accomplished in the face of bacterial contamination, since it is almost impossible to exclude bacteria constantly from an open wound. The reparative process is work- ing at a disadvantage, hence healing is slow, taking several weeks or longer. There is usually inflammation of the injured area, and these granulating wounds are often painful. Serous secretion or purulent discharge commonly occurs. Occasionally wound repair seems to be regressing rather than progressing, or at least to be at a standstill. The explanation of this failure to progress lies in the nature of the factors which influence healing. Factors Influencing Repair. Certain of these Concern the body as a whole; the others are chiefly local. The age and the general health of the patient are important, healing taking place more rapidly in the young and healthy. The presence of a debilitating systemic disease, for example, cancer, tends to delay healing. Since repair is dependent upon the ability of the cells to grow and reproduce themselves, it is obvious that adequate nutrition of the whole body is necessary; especially important are the vita- mins. Adequate nutrition of tissues in the vicinity of the wound is equally necessary, and this is accomplished by the circulating 12 THE FUNDAMENTALS OF SURGICAL NURSING blood. Poor local circulation is a common cause of delayed heal. ing. Then, too, the extent of the local damage to the tissues, not only with respect to the amount of tissue damage, but also with respect to the nature of the injured structures, is obviously a determining factor in the repair. Where a wound communicates with the interior of the lung, intestine, or urinary system a permanent opening (fistula) often results. Infection. The healing of wounds is adversely affected by bac- terial contamination. There are many varieties of microorganisms distributed widely in nature; some of these are harmful to tissues and produce disease in man. Certain pathogenic bacteria are able to destroy the cells of the body tissues, either by manufacturing a specific poison (toxin) or by producing metabolic wastes which are injurious to the living cells. There is great variation in the action of these bacteria and of their poisons upon the differ- ent cells of the body. Thus the unbroken surface of the epi- thelium of the skin or of the mucous membranes affords complete protection against most of these pathogens; it is only when there is a wound, or tiny break in this armor, that a portal of entry is opened. Through this opening, bacteria, if present in sufficient numbers, will penetrate to the subepithelial tissues, which are less resistant. Once present in the tissues of the wound, the bacteria wage war against processes of repair, destroying new cells as well as old. The progress of healing will depend upon the ability of the protective agents of the body to defeat the bacteria. Foreign Bodies. Healing may also be delayed or prevented by the presence of foreign material in the wound. Certain substances are highly irritating to the tissues; in fact, there are very few materials so inert as to be harmless. Such objects as wood splinters or fragments of cloth not only introduce infection, but are of themselves irritating. Wounds are also subjected to unnecessary injury if the injured part has not been properly splinted or sup- ported, because even slight motion may separate the wound edges, thus interrupting repair again and again before firm union can occur. Too frequent or careless dressing of wounds, or the mis. taken use of strong chemicals delays healing by injuring the delicate new cells. Scar Tissue. Certain elements of the body repair tissue by re- generation; these include epithelium, bone, pleura and peri- toneum, peripheral nerves, and some others. Injured or lost epithe. lium is replaced by new epithelium, indistinguishable from the old, and the same is true of the other tissues in this group, each WOUNDS AND HEALING 13 being able to reproduce itselſ. Other types of tissue, notably mus. cle and fascia, do not regenerate, but are replaced by scar tissue. This is also true of various organs of the body in which, despite the regeneration of certain types of cells, the architecture of the organ is not restored, and scarring results. Scar tissue is the end result of the organization of granulation tissue. The wandering connective tissue cells gradually build up dense white tissue which is firm and inelastic. With the passage of time this tissue tends to contract, and thus closes off many of the tiny blood ves- sels. As a result, scar tissue has poor circulation. Subsequent Con- traction is likely to cause deformity if the area is extensive. It is important, therefore, to prevent the formation of excess scar tlSSUle. TREATMENT OF WOUNDS Certain general aspects of this large subject will be considered here, but the details of the treatment of many wounds will be discussed in connection with the surgery of the various regions of the body. The chieſ purpose of the surgeon in treating wounds is to promote favorable healing, with as complete repair of all dam- age as is ſeasible. The first objective is to save the life of the patient, and this consideration may necessitate the control of hemorrhage and the treatment of shock (Chap. 6). Next comes examination of the patient to determine the local damage and the injury to structures lying beneath the skin. Following this, proper measures are taken to increase the comfort of the patient and to secure optimal repair of the injury. Open Wounds Abrasions are treated by cleansing the skin and removing the embedded foreign material. Beneath a nonirritating dressing the skin will heal rapidly. In treating open wounds that cannot be closed because of loss of tissue (avulsion), dressings which are least irritating are used. Sterilized petrolatum gauze is satisfactory when care is taken not to use too much petrolatum, since an excess may prevent escape of secretion and favor maceration of the tissues. The aim in treating these wounds is to secure an epithelial covering as soon as pos- sible in order to hasten healing and to minimize the scar. Plastic grafting procedures are often necessary. Puncture wounds need little local treatment, as the small sur- face wound closes and heals quickly, but it is essential to recog- • 14 THE FUNDAMENTALS OF SURGICAL NURSING FIGURE 7. Approximation of wound edges by interrupted sutures. nize and to treat injuries due to penetration of structures or organs beneath the skin. The conditions requisite to the growth of anaerobic bacteria (anaerobiosis) exist in such wounds; thus the use of tetanus antitoxin is obligatory unless the patient has been previously immunized. In this latter event, a booster dose of tetanus toxoid must be given. Cleansing. In dealing with open wounds the first step is to reduce bacterial contamination. The skin about the wound is gently but thoroughly cleansed with soap and water or other detergent, and the wound itself may be irrigated with warm water or physiologic saline solution. The adjacent skin is then treated with a disinfectant, but care must be taken not to use such agents in the wounds, because the resultant destruction of delicate tissue cells would do more harm than good. Débridement. Foreign material should be gently removed, and all tissue which has been crushed or otherwise devitalized should be excised (débridement). This step not only removes material which can serve as a favorable culture medium for bacteria, but also speeds repair, since the wandering cells would have to digest and remove this material before healing could occur. Bleeding is checked (hemostasis), as excess blood clot also delays healing. Closure and Drainage. The tissues are carefully approximated, layer by layer, so that finally epithelium is in contact with epi- thelium, muscle with muscle, and so on; the defect to be repaired by healing is thus minimized. Undue tension is strictly avoided, for not only will sutures pull out if too tight, but the circulation will be cut off. Where possible, the skin is closed snugly with ap- propriate sutures; but in the presence of considerable contamina- tion, or where oozing of blood cannot be completely suppressed, a small drain, usually of rubber, is left between the skin edges to facilitate the escape of old blood or wound secretion. Antitoxin Administration. The tight closure of an open wound affords the proper conditions for the growth of anaerobic bacteria WOUNDS AND HEALING 15 FIGURE 8. Wound closure by means of vertical mattress sutures, affording very accurate apposition of the edges. FIGURE 9. Satisfactory approximation of wound edges may be accomplished in an emergency by the use of flamed strips of adhesive. in its depths. These organisms grow and divide only in the ab- sence of oxygen. One of them is the bacillus of tetanus. Its spores are widely distributed in nature. This pathogen manufactures a poison (toxin), a small amount of which is highly fatal to man; fortunately, an antitoxin has been discovered and is available for 16 THE FUNDAMENTALS OF SURGICAL NURSING FIGURE 10. Proper splinting hastens healing. use in protecting patients from the effects of this toxin. It is essential, therefore, that patients with wounds in which anaerobic growth is possible shall receive tetanus antitoxin. In recent years a large part of our population has been actively immunized against tetanus toxin by means of injections of tetanus toxoid, a method similar to that employed in the pre- vention of diphtheria. All of the members of the armed forces of the United States have been so immunized, and large numbers of children as well. These patients need not be given tetanus anti- toxin as a part of the treatment of a wound, but should receive a small booster dose of tetanus toxoid. Dressings. Sterile dressings are applied and, if the wound is in a region likely to be subjected to motion, a splint is used. The purpose of applying dressings to a wound is to facilitate healing. As ſar as possible, dressings are designed to protect the wound from mechanical injury, to exclude bacteria, to prevent motion, and to absorb secretion or drainage. Interference with the carry- ing out of normal functions and with the comfort of the patient should be avoided. For general use, dressings made of several layers of sterilized gauze have been found the most practicable. Although not so soft as Cotton, the gauze is more easily separated from the wound and does not leave shreds of material in the wound. Dressings are made large enough to cover a margin of normal skin on all sides of the wound, and thick enough to be protective. They may be held in place by bandages, strips of adhesive tape, or Collodion, depending upon the location and the effect desired. Where much drainage is expected, absorbent pads WOUNDS AND HEALING | 7 made of sterilized raw cotton are placed outside the gauze dress- ing, to be changed as often as necessary. Dressings contaminated by purulent drainage must be properly disposed of in order to prevent spread of infection from one patient to the next. A Con- venient method is to provide paper bags as receptacles for such material; these can later be burned. The same care is taken in the preparation of dressings as in the preparation of the supplies for the operating room. Redressings. Too frequent dressing of wounds is avoided; in the absence of ſever, pain, or other evidence of infection, the wound need not be examined until five to seven days later when the skin sutures are removed. It is important, however, to keep the wound and the dressings dry, as moisture renders dressings permeable to bacteria and macerates the tissues. If there is drain- age from the wound, dressings must be changed frequently. A convenient and practical method of changing dressings in an aseptic manner is by the so-called knife-and-fork technic. For this the surgeon needs the assistance of a nurse and a properly equipped surgical carriage or dressing tray. The Surgical Carriage. The equipment of the Surgical carriage includes sterilized covered receptacles which contain sterilized instruments, gauze sponges, dressings, and towels. In addition, there are unsterile basins, sterile and unsterile bandages, adhesive tape and waxed paper bags, and bottles containing appropriate solutions of Zephiran, ether, acetone and other chemicals of the surgeon's choice. In some hospitals the sterile supplies are indi- vidually wrapped or packaged, instead of being placed in large containers. The essential article of the equipment is a long dress- ing forceps, previously sterilized, which stands in a container filled with a strong disinſectant such as lysol, but with the handle standing above the level of the fluid. By means of this instrument, Commonly called a sponge-stick, the nurse may grasp and with- draw sterile supplies or instruments from their containers with- out contaminating them. Thus by using sterilized instruments in place of unsterile hands, dressings may be performed aseptically. In order to guard against contamination of the sterile supplies remaining in the containers, one must observe the rule that supplies may be taken out but may not be replaced unless the whole container is to be resterilized. Example: Technic of Redressing an Abdominal Incision. The patient is placed in a position that will give him most comfort and yet be convenient for the surgeon. Undue exposure of the 18 THE FUNDAMENTALS OF SURGICAL NURSING § § º &A ° N *Nº. §§ º ſ | / …” •º . ~~ * 2 >~ſt-º jº -- Cº- Sºº §SSº NSSW | FIGURE 11. The surgical carriage. Inserts show knife-and-fork technic. Note that the ends of the dressing forceps, the dressings, and the interiors of the containers are sterile. Surgical dressings by this method pre- vent contamination of wound and dressing carriage. body is avoided. The surgeon removes the dressings, taking care neither to injure the wound nor to inflict unnecessary pain. The old dressing is placed in a paper bag in an unsterile basin at the foot of the bed. The nurse then opens a sterile towel, placing it near the wound. Upon this she deposits with the sterile forceps such instruments and dressings as are needed. The surgeon takes an instrument, usually a forceps, and with it applies the appro- priate solutions and the fresh dressings. In this way wound and WOUNDS AND HEALING 19 fresh dressings are in contact only with sterilized instruments, and there will be no contamination of either wound or surgical carriage except through ignorance or carelessness. Closed Wounds Closed wounds respond well to conservative treatment. Protec- tion of the bruised surface, together with the application of heat and complete rest, aids repair. Heat is useful in two ways: it in- creases the circulation and relieves pain. The treatment of sprains, fractures, and subcutaneous wounds of the chest and abdomen, which are closed wounds, will be considered in later chapters. Bites The bites of men and of various animals deserve special Con- sideration. In addition to the local injury, the bite may serve to inoculate the patient with the virus of a disease carried by the animal, or with a poison secreted by the animal. When the ani- mals are small and have sharp teeth, small puncture wounds re- sult, with little local damage. Larger animals may inflict wounds in which there is considerable laceration, Crushing, and even avulsion of tissue. The mouths of men and of animals are always heavily contaminated with bacteria, so that bites are commonly infected. Human bites produce unusually dirty wounds, a result of the combination of crushed tissue and the bacteria of the human mouth; also to be borne in mind is the possibility of the transmission of syphilis. * In general, the wounds resulting from bites are treated locally as any heavily contaminated wound should be treated, with spe- cial attention to cleansing and débridement and with no attempt at closure. Since suppuration, with consequent loss of tissue and delay in healing, is probable, the prophylactic use of antibiotic agents is justified. Daily intramuscular injections of repository penicillin, until serious inſection is averted or controlled, is one method of accomplishing this aim. The bite of a venomous snake may be differentiated from that of a nonvenomous snake either by recognition of the variety of snake or by the appearance of the wound. Venomous snakes have hollow, needle-like fangs through which the venom is injected into the victim, and these puncture wounds are unlike the marks made by the row of teeth of the nonpoisonous snakes. The toxin secreted by venomous snakes is lethal to man if a sufficient 20 THE FUNDAMENTALS OF SURGICAL NURSING amount reaches the central nervous system. The treatment of snake bite consists in the prevention of absorption of the toxin by slashing open the tissues and injecting physiologic saline solu- tion to wash out the toxin. Where the bite is on an extremity, an effort is made to slow the rate of absorption by the intermit- tent use of the tourniquet, since small sublethal amounts of toxin may be safely metabolized in the body. Neutralization of the toxin by the use of polyvalent antivenin should be tried, and an attempt is made to overcome the paralyzing effect of the toxin by the administration of stimulants to heart and respiration. War Wounds The wounds caused by the implements of modern warfare are far more serious than the wounds incurred in civil life, and, fur- thermore, the exigencies of the battlefield often prevent prompt treatment. The problem which confronts the surgeon is thus vastly different. War wounds are commonly multiple, and there is usually extensive loss of substance. Fractures, if present, are nearly always compound and comminuted. Hemorrhage and shock are conspicuously present. As a rule, such wounds are grossly contaminated by soil, bits of clothing, and other foreign material. The comment may be made that wounds of this nature are not infrequently received in automobile or industrial acci- dents, and that the results of treatment as carried out in Civil life are extremely good; but it must be emphasized that during a battle or an air raid it is not possible to care for all casualties quickly. Thousands of soldiers or noncombatants may be injured in a ſew minutes; transportation and treatment require time, so that many hours or even days may elapse before a given indi- vidual receives any but the most urgent first-aid treatment. Modern treatment of war wounds begins long before the wound is sustained. Each soldier is actively immunized against tetanus toxin, and cleanliness of body and clothing is empha- sized. The first-aid equipment issued to soldiers includes a sterile dressing. The wounded soldier is taken to the nearest casualty clearing station; there, the means for treating shock and for checking hemorrhage are available. The wounded are sorted out (triage), so that those in greatest need of surgery will be trans- ported first to the nearest hospital. At the hospital patients with penetrating wounds of the abdo- men and chest and those with head injuries receive treatment first. Next the compound fractures are dealt with, and finally the wounds of soft parts and simple fractures. It is obvious that WOUNDS AND HEALING 2] ordinary closure of soft-part wounds usually is not feasible, as thorough treatment may not be possible until twelve to seventy- two hours after injury. Nevertheless, the use of antibiotic agents, and careful preservation of all viable structures will result in clean granulating wounds which later may be treated by some type of secondary closure, or by plastic reconstruction, so that good functional results will ultimately be obtained. NURSING CARE The nurse will often see the injured person first, especially in schools, industry, or in the hospital accident room. Effective first aid requires the performance of numerous acts almost simultane- ously. Of nearly equal importance is the cultivation by the nurse of an attitude of calmness, because this last, when Combined with obvious efficiency, gives the greatest reassurance to the frightened patient. The nurse must quickly appraise the situation, and, if necessary, commence artificial respiration, take steps to control obvious bleeding, apply sterile dressings to the wounds, summon help, or administer antidotes, as the case may be. Under some circumstances the responsibility for treating minor, superficial wounds, insect bites, and the like may be delegated to the nurse. When the surgeon is needed and has been called, the nurse should gather useſul information from or about the patient Con- cerning the circumstances of the injury, and should prepare such sterile instruments and materials as may be needed. She should also attend to the notification of relatives if the patient is a child or a seriously injured adult. She may, in appropriate situations, prepare the tetanus antitoxin or toxoid for administration, and may administer the test dose of horse serum in the conjunctival sac if antitoxin is to be used. Following the completion of treatment, the nurse may be as- signed the job of instructing the patient or his relatives concern- ing his care, treatments, and return visits. She should not forget, in carrying out these tasks, that the patient and his relatives are likely to be in a highly abnormal state emotionally, and that they are probably quite unfamiliar with the care of injuries and the medical jargon associated therewith. It is best to state the neces- sary instructions very simply and carefully, and to see that the patient or his relatives can repeat them correctly. Many hospitals have prepared printed instructions to be given to the patient or his relatives. This is a good procedure, but must be accompanied by verbal instructions as well, for there are still some who cannot read or who cannot understand what they read. 22 THE FUNDAMENTALS OF SURGICAL NURSING SUMMARY Living tissues naturally tend to repair wounds. The processes of repair are aided by careful approximation of wound edges, by the control of bleeding, by the removal of dirt and devitalized tissue, and by the prevention of bacterial growth. Healing can be retarded by neglect and by overtreatment. Emergency treatment requires calm thinking and prompt, Correct action. Although a wound is confined, in a strict sense, to a local area it affects the patient as a whole; therefore, total care is as necessary as the care directed to the wound. VOCABULARY REVIEW abrasion contusion anaerobiosis incision hematoma débridement avulsion extravasated antitoxin laceration granulation tissue toxoid fistula SUGGESTED READING 1. Joergenson, E. J., and Smith, E.T.: Postoperative Abdominal Wound Sepa- ration and Evisceration. Am. J. Surg., 79:282-287 (February) 1950. 2. Kleitsch, William P., and Douglas, Dale W.: Postoperative Wound Disrup tion. Am. J. Surg., 84:678–683 (December) 1952. 3. Krause, Marie V.: Nutrition and Diet Therapy in Relation to Nursing, Philadelphia, W. B. Saunders Co., 1952, pp. 223-224. 4. Marshall, Wallace: Some Pathologic Aspects of Cutaneous Wound Healing. Am. J. Surg., 84.675–677 (December) 1952. 5. Rhoads, J. E., Fliegelman, M. T., and Panzer, L. M.: Mechanisms of Delayed Wound Healing in the Presence of Hypoproteinemia. J.A.M.A., 118:21-25 (January 3) 1942. 6. Waterman, Donald F., and others: Healing of Wounds in the Presence of Anemia. Surgery, 31:821–828 (June) 1952. 7. Wolff, William I.: Disruption of Abdominal Wounds. Ann. Surg., 131:534– 553 (April) 1950. CHAPTER 3 Surgical Infections The human body is admirably equipped with armor against bac- terial invasion; every exposed surface, whether skin or mucous membrane, is covered by a continuous sheet of epithelial cells. SURGICAL INFECTIONS 23 No one can go through life, however, without an occasional break in this armor, and when an opening is made, no matter how small or how temporary, bacteria are always present to take ad- vantage of the opportunity. Once the bacteria are beneath the surface, infection has occurred, and the body must mobilize its defenses against the enemy. Since an important factor in this struggle is the number of pathogenic microorganisms present, the value of cleanliness is apparent. Dirt harbors germs. Those to whom the care of patients with infection is entrusted can hardly escape contact with virulent bacteria, and thus their own safety depends largely upon cleanliness. Regular washing of the hands after such contacts, together with frequent change of clothing, is important. Injury to the hands from unnecessary or rough scrubbing should be avoided, as it is of the utmost im- portance to prevent breaks in the skin. Visits to patients with un- infected wounds should be made before attending to those with infection. An occasional postoperative wound infection seems unavoid- able, but the occurrence of an infection following the perform- ance of a presumably aseptic procedure indicates a break in technic. For this reason surgeons and nurses must make it their duty to record every postoperative infection, and to investigate fully all the circumstances so that errors in technic can be cor- rected and carelessness or ignorance exposed. The spread of infec- tion from patient to patient, so common in bygone centuries, is inexcusable now, and must be considered as due solely to the carelessness or inefficiency of those caring for the patients. Body Defenses Against Infection. The Chief antagonists of bac- teria are the phagocytic (swallowing) white corpuscles of the blood, which can surround and engulf bacteria, and the wonder- ful chemical substances called immune bodies. These last are found in the blood and in the tissue fluids; some (antibodies) have the power to inhibit the growth of bacteria, some (co- agulins) to cause them to adhere to one another, and others (lysins) to dissolve them. The outcome of the struggle depends upon the ability of the body to mobilize and deliver leukocytes and immune bodies. The local concentration of these defenders occurs in the inflammatory reaction, and the old description of inflammation, pain (dolor), swelling (tumor), redness (rubor), and local heat (calor), remains adequate. The inflammatory reac- tion is nonspecific; that is, it may be provoked by irritants other than bacteria. Capillary dilatation results in increased local cir- culation of blood, producing erythema and local warmth. Leuko- 24 THE FUNDAMENTALS OF SURGICAL NURSING cytes and serum, spreading among the tissues, cause swelling. The irritation of the local nerves is responsible for the pain and ten- derness. The region now contains bacteria, more blood than usual, leukocytes, and tissue fluid. In addition to the Swelling, the tissue feels hard when palpated; such abnormal consistency is known as induration. The bacteria are surrounded on all sides, and this stage of the infection corresponds to the clinical term cellulitis. Systemic Response. Accompanying the local attack upon the bacterial invaders is a response of the whole body. This, when sufficiently severe to be noticeable, is characterized by a general feeling of illness (malaise), ſever, loss of appetite, and sometimes headache. The symptoms vary, of course, with the size and Con- dition of the patient, and with the nature and number of the bacterial invaders. At this stage in the inſection at least three different results are possible. The bacteria may be quickly overcome, in which case the inflammation disappears and the inſection is over. Or, if the bacteria are more resistant, the inſection is localized but proceeds to suppuration. Or again, the bacterial invaders may be stronger than the defense, and the infection spreads. Abscess Formation. When the infection is not quickly over. come, the leukocytic infiltration about the bacteria increases. If this ring of defenders is successful in confining the bacteria, an abscess forms. During the next period of days or hours, the cen- tral mass of bacteria, leukocytes, and cellular debris liquefies as a result of the action of ferments brought by the blood or secreted by bacteria. The presence of this yellowish liquid (pus) may be detected by the sudden softening of the central portion of an indurated area, or by the appearance of fluctuation, a sign which is dependent upon the transmission of impulses by an enclosed collection of fluid. Following the evacuation of the pus, the ab- scess cavity collapses, its walls fall together, and healing occurs exactly as in granulating wounds. Failure of Local Resistance. The body requires a certain amount of time to mobilize its defenses; often the bacteria are present in such overwhelming numbers that the early local re- sistance is unable to prevent the spread of infection. On occasion the bacteria gain entrance to the blood, causing septicemia, but the usual mode of spread is either along fascial planes or through the lymphatics. Thus a deep-lying inſection—as, for example, an abscess beneath the palmar fascia of the hand—will extend be- SURGICAL INFECTIONS 25 º \\ Epidermis () 3º §§º Enº, 㺠& FIGURE 12. The common furuncle (boil). neath the fascia up into the forearm since there is less mechanical resistance in that direction. Superficial infections are apt to enter the lymphatic system. The nature and function of this system of vessels and glands are considered in some detail later; it is enough to say here that bacteria entering the lymph channels and nodes meet with fierce resistance. The familiar clinical pic- ture of red streaks extending from an inſected hand up the arm toward the axilla (lymphangitis, Fig. 13), is due to the inſlam- matory reaction along the lymphatic vessels. It is erroneously known by the laity as “blood poisoning.” These vessels drain into the lymph nodes, where further attempts are made to overcome the bacteria. All grades of the inflammatory process may occur in the infection of lymph nodes (lymphadenitis), and breakdown with suppuration is common. Bacterial Invaders. The staphylococcus and the streptococcus are the commonest causes of surgical infection. In general, the 26 THE FUNDAMENTALS OF SURGICAL NURSING .SITE OF INFECTION - , FIGURE 13. Lymphangitis and lymphadenitis caused by extension of the infec- tion from the hand. staphylococcus is more apt to cause localized infection with ab- scess formation, whereas the streptococcus seems more virulent, producing more profound systemic effects and tending more often to spread through the tissues and the lymphatics. The Colon bacillus (Escherichia coli), the pneumococcus, and a few others are occasionally encountered in primary infection, but the colon bacillus is often present in wound infections following operations on the gastrointestinal tract. Most of these bacteria live equally well on the surface of the body or in the tissues. Some bacteria, however, thrive only in the absence of free oxygen (anaerobiosis); one variety of anaerobic streptococcus produces a particularly de- structive and spreading infection. Among the bacteria found in the mouth are certain putrefactive anaerobes, and these play a part in infections due to bites and in pulmonary infections. SURGICAL INFECTIONS 27 NURSING CARE OF SURGICAL INFECTIONS Infection. The occurrence of unexplained fever or of undue inflammation about a recent wound points to a wound infection. Often the local signs are slight, but usually there are increased tenderness and induration. The early discovery of a wound in- fection is of the utmost importance, since neglect may lead to a spreading of the process with results that are disastrous to the success of the operation or even fatal to the patient. It is the purpose of the surgeon to aid the body in its fight against infection, hence certain general measures are undertaken in the treatment of every inſection, however trivial it may seem. These measures include enforced rest, not only of the infected part but of the whole body, adequate diet, and relief of pain. Efforts are made to increase the local circulation in the infected area. When pus forms it should be permitted to escape by means of adequate surgical drainage (p. 35), but any surgical procedure which might spread the infection is avoided. The local applica- tion of heat and prompt opening of the wound are indicated. Numerous antibiotic and chemotherapeutic agents and prepared immune bodies (immune serum and antitoxin) are now avail- able, to be used when indicated by the severity and nature of the infection. Where the infectious process has resulted in considerable de- struction of tissue it is advisable to remove the necrotic material; an effective method is by irrigation with Dakin's solution. To be active this solution must be freshly prepared, and it may be used in any wound where there is no danger of hemorrhage, or where no delicate tissue, such as brain, is exposed. Since it is irritating, the adjacent skin must be protected by a layer of grease. In addi- tion to removing necrotic tissue and destroying bacteria, Dakin's solution is a strong deodorant, a quality much appreciated by patient and attendants when a foul, sloughing wound is present. Azochloramid, a more stable and less irritating chemical, may be used in place of Dakin's solution. Further infection of the patient and transmission of the germs to others must be prevented by the proper disposal of pus, dressings and other contaminated articles. Measures to Improve Circulation. To aid the local circulation of blood, the infected part should be supported at the level of the body. This may best be accomplished by keeping the patient in bed; when the infection is minor, however, such as an infected extremity, placing the infected hand in a sling or elevating the 28 THE FUNDAMENTALS OF SURGICAL NURSING FICURE 14. Treating an infection by the application of dry heat (carbon fila- ment lamp). inſected foot upon a chair while the patient is seated is helpful. Constricting bandages or clothing should be avoided. Heat. The local application of heat produces increased blood flow in the area treated, and is also mildly analgesic. Heat may be applied in several ways; dry heat is conveniently obtained from a carbon filament heat lamp, moist heat by the application of hot compresses, or by the immersion of the part in a tub of hot physio- logic saline. Heat may also be derived from the use of electro- diathermy. Since heat is a potential source of burns, extreme Cau- tion must be observed in the method of its application. The use of electric heating pads is dangerous; serious accidents have occurred from overheating, and electric shock has followed the moistening of the pad. Diathermy requires Complicated apparatus and especially trained operators; hence its use is somewhat limited. DRY HEAT. In using dry heat therapy, numerous considerations must be kept in mind, such as individual differences in resistance to heat, the size of the area to be treated, the energy output (wat- tage) of the lamp, the size of the reflector, and the distance of the source of heat from the body surface. When equipped with a small reflector, a 300-watt carbon filament lamp (infra-red) (Fig. SURGICAL INFECTIONS 29 FIGURE 15. Application of moist heat by use of an arm tub. 14) is satisfactory. This lamp has the advantage of producing less light than the thermolite type of lamp, and is thus more comfortable to the patient's eyes. An average distance of 30 inches between lamp and body surface provides sufficient heat, but a safe guide is the sensation of the patient, which should be no more than a feeling of pleasant warmth. When the patient's sen- sation is not a reliable guide (as with children, mental patients, or in neurological conditions), the nurse's hand at the same dis- tance may be used, or better, a thermometer on the skin surface, with the temperature not over 110° F. Care must be taken so that only a small portion of the total body surface is exposed, since dangerous overheating might otherwise result; periods of ex- posure should be limited in time (one hour or less) and should be alternated with equal periods of rest. MOIST HEAT. When moist heat is applied it is well to protect the skin with grease in order to avoid maceration. With a lesion draining infected material, the use of an antiseptic grease, such as 5 per cent ammoniated mercury ointment, is advisable, to pre- vent wholesale inoculation of the adjacent skin. Hands and feet may be treated by immersion in tubs of physiologic salt solution heated to 105 to 112° F. The temperature may be maintained at that level, or even a little higher iſ not uncomfortable for the patient. 30 THE FUNDAMENTALS OF SURGICAL NURSING Dressing towel Koroszal Comprass yº \l w ºn' * 2. FIGURE 16. Application of moist warm compresses. A sheet of plastic may be used in place of oiled silk. It is convenient to keep a thermometer at the bedside for test- ing the temperature of the solution. The maintenance of a fairly even temperature is accomplished by adding solution every half hour. The extremity should be removed from the tub when fluid is added. The solution should be thoroughly mixed before re- placing the arm or the leg in the tub in order to prevent a burn. It is difficult to make a patient with a severely infected extremity comfortable; he is often fatigued, irritable, and hypersensitive. Relief at night from the continuous tub may be gained by the application of a hot compress with the part elevated on a pillow. This alternating treatment affords better relaxation since the position in bed is more comfortable; longer intervals of sleep may be obtained because there is less frequent disturbance. Rest les- sens ill temper, anxiety, and fretſulness. Elsewhere about the body, moist heat is derived ſrom the ap- plication of compresses. These are made of several thicknesses of any suitable material, usually gauze, are sufficiently large, and are applied directly to the inſected area. Sterilization of com- presses, basins, and Solutions is carried out whenever there is an open lesion or wound. The compresses and solutions are heated to 125° F., following which the nurse, having previously cleansed her hands, wrings out the compress and applies it to the in- SURGICAL INFECTIONS 31 ſected area. The compress is then covered with plastic ma- terial which extends slightly beyond the edges of the Compress, and the whole is held in position by a dressing of bandage or towels. A triangular bandage is often useful for this purpose, as is also a binder. The heat will be maintained at temperatures of 92 to 96° F. throughout the entire compress because plas- tic materials are excellent insulators. Frequent changing of compresses is necessary to prevent the accumulation of drain- age or secretion on the infected surface. At times solutions other than physiologic saline are advisable, and under certain cir- cumstances, usually to prevent damage to delicate tissues, Com- presses are moistened at intervals without being changed. When compresses are used on healing wounds (granulation tissue) and are changed as infrequently as every four hours, it is ad- visable to moisten the compress well before removing it, since the underlying tissue may be adherent; unnecessary trauma is thus avoided. Cold. The use of ice or cold packs has been advocated for the treatment of infections, but there is no physiologic basis for their use. Lowered temperature results in constriction of the blood ves- sels and a slower cellular metabolism, which are disadvantageous. Refrigeration. In some situations, however, the use of refrigera- tion may be a means of saving life. Chilling an extremity by pack- ing it in ice or immersing it in solutions cooled below the freez- ing point of water has the effect of slowing the circulation locally, lowering the rate of all metabolic processes, and checking bac- terial growth and invasion. By this means time may be gained for the regulation of uncontrolled diabetes mellitus in a patient with spreading inſection in a gangrenous extremity. Amputation can then be postponed until it can be carried out safely. Technic of Refrigeration. Before the treatment is begun, the nurse should give the patient a simple explanation Concerning it. When the extremity is painſul, it is desirable to give the patient an analgesic, such as morphine, at least twenty minutes before the procedure is started in order to prevent excruciating pain at the onset of chilling, before anesthesia is produced by the cold. It is also important that the nurse obtain from the surgeon in- formation as to the exact site where refrigeration is to begin. To hasten thorough chilling of the deep tissues, surgeons, at times, apply a tourniquet below the level of the intended amputa- tion. To prevent pain due to its application, it is usually not adjusted until twenty minutes after refrigeration is begun. 32 THE FUNDAMENTALS OF SURGICAL NURSING U-y FIGURE 17. Use of plastic boot for refrigeration. A plastic boot, as illustrated in Figure 17, is most useful. The leg is placed inside the boot, and the tape tied securely around the leg over the outer and inner boot at the level ordered by the surgeon. Finely crushed ice is then inserted through the zipper opening and packed around the leg and foot; the latter is pro- tected by the inner plastic boot. Care should be taken that the leg and foot are uniformly covered with a layer of ice of not less than 3 inches. To help keep the ice in place around the leg as melting takes place, the straps on the outer boot are securely buckled. The drainage tube is extended over the edge of the mattress at the foot of the bed into a basin. A flannel blanket is then placed over the boot to protect the patient's other leg from the cold boot. The bed covers can then be neatly arranged. This method of refrigeration offers many advantages. Re- frigeration may be constantly maintained for as long a period as necessary and there is no seepage of water to make the patient uncomfortable. The flannel lining of the outer boot prevents the condensation of moisture. The patient may be taken to the oper- ating room with the boot in place, and it may be removed with- out spilling water or ice. Another method of administering refrigeration is by wrapping a large rubber sheet and a muslin sheet around an extremity, placing the ice between the extremity and the rubber sheet. The ice and rubber sheet are held in place by pinning the muslin sheet. The end of the rubber sheet may be arranged so that the SURGICAL INFECTIONS 33 melted ice will drain into a bucket on the floor or on a stool at the foot of the bed. To help prevent seepage around the thigh, the head of the bed should be elevated on shock blocks at a level of 6 to 8 inches. In addition, a strong tape may be securely tied around the sheet and leg at the site ordered by the surgeon. This not only helps prevent the seepage of water but also permits uniform anesthesia where the amputation is to be done. The equipment necessary for this procedure is easily assembled, but it is difficult to add ice. Seepage of water usually takes place in spite of care and it is very difficult to move the patient. Sulfonamides. Chemotherapy, the treatment of disease by chemical compounds, has long been one of the chief aims of scientific medicine. A development of recent years has been the discovery of the sulfonamide drugs (sulfanilamide, sulfapyri- dine, sulfathiazole, sulfadiazine, and sulfamerazine). Sulfadiazine is particularly useful in combating infection due to the virulent hemolytic streptococcus. In some way, this drug, while circulating in the blood and through the tissues, seems to inhibit the meta- bolic activity of the bacteria so that they cease to grow and divide and are thus more easily overcome by the normal defenders of the body, the phagocytic cells. The other members of this sulfona- mide group are useful in specific infections and will be discussed in later chapters. The important considerations in the use of sulfonamide drugs are administration of sufficient amounts early in the disease, Careful observation to discover toxic manifestations, and Con- tinuous use of the drug until the infection is completely healed. Toxicity. In certain sensitive persons toxic manifestations, in- cluding anemia, fever, skin eruptions, renal damage, and de- lirium, appear. Nausea and cyanosis are common. Dosage. These drugs may be administered by mouth or paren- terally. The dosage is controlled by frequent estimation of the amount of drug in the circulating blood. Once a satisfactory blood level is established, enough of the drug is given to replace that which is excreted. Sodium bicarbonate in equal amounts is usually administered with the sulfonamides, in order to render the urine more alkaline and thus increase the solubility of the excreted drug. This precaution reduces the frequency of renal damage. Prophylactic Therapy. Of equal importance is the prophylactic use of sulfonamides. When administered properly before surgical procedures are carried out, these drugs have appeared to prevent infection when it seemed inevitable; this result has no doubt been 34 THE FUNDAMENTALS OF SURGICAL NURSING achieved by increasing the resistance of the tissues, so that larger numbers of contaminating bacteria can be successfully OVCTCOIſle. Antibiotics. At present, however, the newly available antibiotic agents have largely supplanted sulfonamides in the treatment of infections. That certain substances, manuſactured by or derived from growing organisms such as ordinary bread mold, possessed the ability to inhibit bacterial growth has been known for many years. During World War II, stimulated by the urgency of the need, means were devised to mass-produce one of these sub- stances, penicillin. Since then, others have been made available for clinical use, including streptomycin, aureomycin, tyrothricin, bacitracin, chloramphenicol, and Terramycin, and the list is still growing. While each of these agents is effective against a wide variety of pathogenic bacteria, there are some specific indications for their use. Administration of Antibiotics. One problem that arises from the numerous antibiotics ordered for patients is that so large a portion of the total nursing time available for patient care is thus utilized. Nursing time can oſten be saved by efficiency in posting the hour of administration. The posting of as many medications as possible to be given at the same time permits the nurse to prepare them for all assigned patients at one time. Preparing in- jection of two antibiotics in one syringe, such as dihydrostrepto- mycin and penicillin, results in only one injection, thus lessening discomfort and conserving time. However, combinations of anti- biotics should not be prepared in one syringe unless specifically ordered by the doctor. Certain antibiotics are given intramuscu- larly because there is less pain and better absorption than when given by subcutaneous injection. Toxicity. The widespread use of antibiotics has disclosed the fact that some individuals are or become specifically sensitized to these agents, whether the antibiotic is administered orally, topically, or parenterally. The sensitivity phenomena produced vary from mild, transitory urticaria (itching hives) to such severe symptoms as asthma, dermatitis, edema, spontaneous bleeding, and prostration. The appearance of any of these manifestations is cause for immediate alarm and halting of the administration of the antibiotic in use. Fortunately, an individual who is sensitive to one antibiotic is not necessarily sensitive to others, so that treatment of the inſection can be continued by switching to an- other of these agents. Most of the antibiotics in common use have SURGICAL INFECTIONS 35 no toxic effects other than the occasional sensitivity just de- scribed, but streptomycin and dihydrostreptomycin, if used over long periods, may cause permanent damage to the inner ear. Loss of hearing and disturbance of gait due to injury to the apparatus responsible for maintel.ance of equilibrium may follow. Tyro- thricin and bacitracin may be used safely only by application to external surfaces, and are not used systemically. Technic of Surgical Drainage. When suppuration has occurred, evacuation of the pus is in order; general measures and chemo- therapy will not accomplish this. If the infection is neglected, the pus may rupture through the skin with spontaneous drain- age and cure, or it may burrow through the tissues with Conse- quent spread of the infectious process. Timely incision will provide drainage and prevent this spread. In performing surgical drainage, care must be taken not to damage important structures or to open new channels for the spread of the process. The open- ing should be made at the most dependent portion of the abscess so as to enlist the aid of gravity in evacuating the pus, and the opening should be maintained until all pus is evacuated. It is for this last purpose that drains, usually of rubber, are employed. During the period of healing, care should be taken to prevent in- ſection of the adjacent skin, which is necessarily exposed to the drainage. Technic of Isolation. Certain of the bacterial invaders, notably the spore-bearing, gas-ſorming, anaerobic Welch bacillus and the hemolytic streptococcus, are so easily transferred from the in- fected patient to any other patient that special precautions must be observed. The transfer of organisms is prevented by means of rigid isolation technic. The infected patient is placed in a sepa- rate room, and all the materials needed for his care are kept in that room. As far as possible the nurses and orderlies assigned to the patient treat only him, and they wear gloves, gowns, and masks. All dishes, dressings, and other objects taken out of the room are properly disposed of by immediate sterilization or burning. The dressing cart and utensils used in the care of other patients are never taken into the isolated patient's room. The room and all its contents are disinfected and aired after each occupation. SUMMARY The human body defends itself actively against bacterial in- vasion. Good nursing care supplements and guards against inter- 36 THE FUNDAMENTALS OF SURGICAL NURSING ference with this natural defense. Rest, the application of heat, refrigeration, and antibacterial agents may be used as aids. VOCABULARY REVIEW phagocytic abscess lymphadenitis antibodies leukocyte diathermy induration pus antibiotic cellulitis septicemia chemotherapy malaise lymphangitis SUGGESTED READING 1. Preventing Infection in Wounds and Burns. Am. J. Nursing, 42:1165 (October) 1942. 2. Christopher, Frederick: A Textbook of Surgery. 5th Ed. Philadelphia, W. B. Saunders Co., 1949, pp. 24–63. 3. Kotin, Paul: Techniques and Interpretation of Routine Blood Cultures. J.A.M.A. 149:1273–1275 (August 2) 1952. 4. Krause, Marie V.: Nutrition and Diet Therapy in Relation to Nursing. Philadelphia, W. B. Saunders Co., 1952, pp. 154–163. . McAllister, Sara E., and Pulaski, Edwin J.: A Technic for Dressing Septic Wounds. Am. J. Nursing, 47:396-398 (June) 1947. 6. Pulaski, Edwin J., and McAllister, Sara E.: Streptomycin Therapy and Infec tions. Am. J. Nursing, 47:89–91 (Feb.) 1947. 5 CHAPTER 4 Neoplastic Disease A neoplasm is an adventitious growth of new tissue. Once thought to be parasitic upon the human body, neoplasms are now known to be composed of tissue cells originating from those of the person affected. Neoplastic disease seems to be the result of a local dis- turbance of the natural, orderly growth of cells, as though the usual regulating influences were not functioning properly. Thus the cells of a single region grow more rapidly and divide more frequently than normal, producing a local increase in tissue, or swelling, to which the ancients gave the name tumor. Why tumors form is a subject not yet fully understood. Many theories have been advanced but none of them fits every case, nor is it likely that there is only one cause. One theory, which seems FIGURE 18. A, Benign epithelial papilloma; B, squamous epithelioma (cancer), showing invasive downgrowth of malignant Cells. to explain the origin of many tumors, holds that the new tissue growth arises as the result of repeated interference with the natural process of repair. The growth of tumors in chronic ulcers and the production of tumors by chronic irritation, particularly by certain coal tar derivatives, are put forward in support of this theory. A second theory is that many tumors arise from small de posits of cells remaining ſrom some developmental stage of the ſetus, the embryonic rests. This theory affords a plausible ex- planation of such tumors as arise from the ovary and testis, and certain cystic tumors which will be discussed later; but no ade- quate reason is offered to explain why such cells produce a tumor occasionally but not always. That neoplasms are due to an infectious agent has been sug- gested, and indeed there is in animals a tumor which is transmis- sible by a filtrable virus, the Rous chicken sarcoma. No evidence has been discovered, however, to show that any human tumor is transmissible or is due to any known inſection. Whether neoplastic disease is hereditary or not is a subject of Controversy. The occurrence of similar tumors in many members of one ſamily is not uncommon: yet such happenings may be coincidental and of no real significance from the standpoint of heredity. Recently it has been shown that the production and growth of some tumors are inſluenced by the secretions (hormones) of cer. tain of the endocrine glands. Differentiation of Benign and Malignant Neoplasms. The chief difference apparent between benign and malignant tumors is one of degree. In benign tumors, cellular growth is scarcely less orderly than in normal tissue, and the microscopic appearance 38 THE FUNDAMENTALS OF SURGICAL NURSING Metastases, from Carcinoma of the Stomach supraclayicular Thodes sº §§ & N Rºs - & Rºxº S& Sº § sº sº Nº º º º º sº Kºrº º & & Vº ES ºrrº º §§§ º Vº wºº § º º &NY:TA §§§N 2: &S §§ tº \ ...dºc Nºteks § Nº Neºs: §'AºNä * §§ PRIMARY Šºć #sº GROWTH -zº Sº º: **** FIGURE 19. Carcinoma of the stomach may spread to the pancreas and perito- neum by direct extension; metastases reach the liver through the portal vein; lung and bone metastases follow invasion of the blood stream, but the supraclavicular metastases result from invasion of the lymphatic system (thoracic duct). of the benign tumor cell is not different from that of a normal cell of the same type of tissue. Benign tumors grow slowly and remain in their original locality. Their effect upon the patient depends chiefly upon the size attained by the growth. There may be pain and injury to neighboring structures as a result of the pressure caused by the expanding growth, but the cells of the tumor remain distinct, and are separated from the adjoining tissues by a capsule of fibrous tissue. NEOPLASTIC DISEASE 39 Malignant tumors, on the other hand, are characterized by the lack of any restraint of growth. The malignant cells grow rapidly and irregularly, so that in appearance they differ widely from one another and from the original cell type. This characteristic alteration is called metaplasia. Even more typical of the malig- nant tumor cell is its ability to invade the adjoining tissues. No capsule is formed. It was the many-legged appearance of the invasive tumor growth that led the ancients to see a resemblance to the Crab; hence the name cancer. As a by-product of this in- vasive ability, malignant tumor cells may be scattered through the body; traveling through tissue spaces, lymphatics, and blood vessels, they produce islands of tumor far removed from the original growth but similar to it in every way. These remote new growths are called metastases, and are themselves as malignant as the parent tumor. By reason of their rapid growth, invasiveness, and tendency to metastasize, malignant neoplasms affect the individual disas- trously. A malignant tumor, if allowed to progress, will prove fatal. Death is due to various circumstances, such as erosion of a blood vessel with hemorrhage, or metastatic invasion of the brain or lungs, or interference with the nutrition of the patient as in neoplastic disease of the gastrointestinal tract, or a progressive Weakness (cachexia) which many malignant tumors, when far advanced, seem able to produce. Benign tumors, fortunately, are far more common than malig- nant ones. There is not a person who does not have at least one minor skin tumor, such as a mole, a wart, or a hemangioma. Malignant tumors more often attack older people, although oc- casionally infants and children have them. Despite recent ad- Vances in knowledge, malignant disease continues to be one of the leading causes of death. NOMENCLATURE It would be unnecessarily confusing to list even a few of the many names of the different kinds of neoplasms. Tumors are classified according to their appearance under the microscope, and this, in turn, depends upon the type of tissue cell from which the tumor cells arise. The suffix oma denotes tumor; thus epi- thelioma is a tumor of the epithelial cells, and lipoma is a tumor of fat cells. There are certain terms which are of more general usage; thus, carcinoma (cancer) signifies any malignant tumor of epithelial origin; sarcoma signifies any malignant tumor of con- 40 THE FUNDAMENTALS OF SURGICAL NURSING nective tissue origin; and glioma signifies any malignant tumor of central nervous system origin. The descriptive nature of the various prefixes used, such as osteo- (bony), adeno- (glandlike), or chondro- (cartilage), needs little explanation. The names and cell types of some of the commoner tumors are listed in Table 1. Tumors often contain a mixture of tissues; examples of this are fibroadenoma of the breast and adenomyoma of the uterus. An- other example is the teratoma, a very interesting type of tumor, which probably arises from embryonic cells since it may contain epithelium, Connective tissue, hair, teeth, bone, nervous tissue— in a word, all the elements of the body. It is as though the indi- TABLE 1. Tumor Nomenclature CELL TYPE BENIGN TUMC).R MALIGN ANT TU MOR Skin epithelium Wart Epithelioma Gland epithelium Adenoma Adenocarcinoma Connective tissue Fibroma Fibrosarcoma Muscle Myoma Rhabdomyoma Cartilage Chondroma Chondrosarcoma Bone Osteoma Osteosarcoma Blood vessel Hemangioma Hemangiosarcoma Nevus cell Mole Melanotic sarcoma vidual had given rise to a maldeveloped twin, or to a bud like that of a plant. Tumors which arise from the secreting glands of the body are usually functionless, but occasionally an adenoma or adeno- carcinoma produces the secretion of the original gland. When the product happens to be a potent hormone, the physiology of the patient is Correspondingly affected. TREATMENT OF NEOPLASTIC DISEASE Since the cause of neoplastic disease is still unknown, treatment is based upon experience and upon the relieſ of symptoms as they occur. That the cure of a patient suffering from neoplastic disease can be brought about by the removal of the neoplasm is an old idea, and a correct one. The difficulty lies in the accomplishment of complete removal; moreover, the removal of one tumor does not prevent the development in the same patient of a second, altogether distinct neoplasm. Benign Tumors. Benign tumors can be completely removed surgically unless the tumor happens to be in an organ or a struc. NEOPLASTIC DISEASE 41 ture which will not tolerate operation. Fortunately, the occur- rence of benign tumors in such locations is uncommon; there- fore, benign tumors are curable. The student nurse, however, may rightly inquire into the reasons for the removal of benign tumors, the more so since every person supports a few of them uneventfully. The removal of a benign tumor is justifiably under- taken when it is causing symptoms by virtue of its size and posi- tion, or when symptoms are impending as a result of its growth. Endocrine disturbance resulting from the oversecretion of a hormone by an adenoma is likewise good reason for removal. Be- nign tumors located so as to invite frequent trauma, and those which suddenly start growing rapidly should be removed to ſore- stall the transition of the benign tumor into a malignant one. In addition, the removal of conspicuous, disfiguring tumors is often justified for the cosmetic effect. Many methods are available for dealing with benign tumors, including surgical excision, desiccation by electrocautery, chemi- cal cauterization, freezing with carbon dioxide snow, and irradia- tion with x-ray or radium. It is important that a method be used which is adequate, for incomplete removal of a benign tumor will not only fail to cure the patient, but may even add to his trouble by causing the benign growth to undergo malignant degenera- tion. In evaluating these various methods it is fair to say that the best results follow surgical excision, and that other methods are to be used only when excision is not feasible. Malignant Tumors. The very nature of malignant tumors Con- stitutes a formidable obstacle to successful treatment. Just as in the case of benign tumors, the cure of a malignant neoplasm de- pends upon removal or destruction of the entire tumor. The extent of such tumors is not clearly defined, however, since there is malignant infiltration in every direction, and the surgeon may find it difficult to know how much tissue to remove. The oc- currence of metastases, moreover, with the resultant growth of re- motely situated daughter tumors, obviously precludes all pos- sibility of cure. Added to these difficulties is another dread fea- ture of malignancy, the insidious, symptomless onset of the cancer. Pain or other symptoms do not occur until the tumor has been present for a considerable time, and the unfortunate patient may be beyond all hope of cure before he feels the need of con- Sulting a physician. It is to be hoped that the time will come when the medical profession will have in its hands a method by which cancer in all 42 THE FUNDAMENTALS OF SURGICAL NURSING stages can be cured. At present, however, the cure of malignant neoplastic disease depends upon early diagnosis, before metastasis has occurred, so that complete surgical removal or destruction by radiation may be accomplished. Many operative procedures for the treatment of neoplastic disease have been developed, and some of these are described in later chapters. A by-product of the accomplishment of nuclear fission and the atom bomb has been the production of radioactive isotopes. Some of these, notably radioactive phosphorus and iodine, are being used experimentally in the diagnosis and treatment of cancer. Many other chemical agents, particularly those capable of affecting the growth of cells, are being studied in the hope of finding some means of aiding the cancer patient who is beyond surgical help. Cancer Defection. Cancer is dreaded by all, and not without reason. Too often it is this fear which robs the patient of his chance of Cure, since many people do not consult a physician when symptoms first appear because they are afraid their sus. picions will be confirmed. It is the duty of every nurse to aid the medical profession in educating the public to make the most ad- vantageous use of the facilities now available for the early diag nosis and treatment of neoplastic disease. All uncertainty in the diagnosis of cancer is removed by making use of the simple pro- cedure known as biopsy (surgical removal of a small portion of any suspected lesion). Tissue obtained by biopsy, or by needle aspiration, or from secretions is examined under the microscope. There is no hazard, and the information thus gained is of im- mense value. NURSING THE PATIENT WITH CANCER Because cancer is recognized as a major health problem, it is essential for the nurse to have a basic knowledge of the facts about cancer so that she may aid in its control and carry out her responsibilities in the care of the preoperative, postoperative, long-term and terminal patient. Early diagnosis and early treatment are the principles which are used in the control of cancer. Education directed toward the layman has stressed that the cure oſ cancer is dependent upon an early diagnosis followed by adequate treatment. The nurse, in her intimate contact with people, is obliged to develop a high index of suspicion concerning cancer. She must discipline her own attitude if she is to be effective and alert to the early signs and symptoms. The seven danger signals which the American NEOPLASTIC DISEASE 43 Cancer Society has used effectively in its vigorous effort to teach lay people and professional nurses the signs and symptoms of the commonest ſorms of cancer should be familiar to every nurse. They are: . Any sore that does not heal . A lump or thickening, in the breast or elsewhere . Unusual bleeding or discharge . Any change in a wart or mole . Persistent indigestion or difficulty in swallowing . Persistent hoarseness or cough . Any change in normal bowel habits Should the patient who has cancer be informed of it? In each instance, the nurse must rely upon the judgment of the surgeon. Some patients do not know they have cancer, prefer not to know it and need not be told. Others know that they have cancer or strongly suspect it, but do not wish to have open Confirmation. Most patients, however, are emotionally stable, well-adjusted in- dividuals who frequently have a sound religious faith. They are helped most by being told. They are often no less fearful than the others, but are able to accept the knowledge of cancer better because they are accustomed to keeping their emotions under control and, probably, because they have come to some sort of resignation, at some time or another, about accepting the hazards of living, including cancer. What should the nurse tell the patient when he asks, “Do I have cancer?” This question should be answered in accordance with the desire of the surgeon, who must carefully instruct the nurse in each situation. An evasive answer serves only to Confirm the patient's suspicion. The reason that the nurse frequently does not know what to say is that she is seized with fear. She should be aware that her reactions are transmitted quickly to the patient and, if there is lack of confidence or hesitancy, the patient loses faith. It is, therefore, important that the nurse answer confidently and reassuringly. The more experienced nurse has an unusual opportunity to help the patient when he asks if he has cancer. She may ask calmly and sympathetically, “Why did you ask the question?” or “Do you think you have cancer?” The patient is anxious and is usually very responsive. She fre- quently learns that the patient knows he has cancer, strongly suspects it, or imagines it and she finds out many things that worry him. When the nurse is a good listener, she can do much to relieve his anxiety by encouraging him to talk; but it is her 44 THE FUNDAMENTALS OF SURGICAL NURSING responsibility to share what she has been told with the doctor So that he may give guidance and support in whatever way may be necessary. The nursing of patients who have had operations undertaken ſor the cure of cancer presents the problems incident to the type of operation performed and to the general condition of the pa- tient. In all cases, the teaching of self-care should be carried out in order to encourage self-sufficiency. The first portion of Con- valescence of the patient who has a laryngectomy, a Colostomy or an amputation is oſten a period of great despair. He feels that he will not be able to adjust to the activities of a normal life. The depression that follows such surgery may be prevented to some extent by proper indoctrination beſore operation but, when it does occur, it can be overcome by good rehabilitation. Teaching self-care to the greatest possible degree will help the patient master his handicap so that he may again take his place in SO- ciety. Occupational and diversional therapy help divert the atten- tion and bolster the morale of patients and should be encouraged in all—whether the illness is long-term or relatively short. Nursing the Patient During Radiation Therapy." Before radio- therapy is begun, the patient should have a good understanding of how the treatments are carried out, what will happen to the tumor and what will happen to him. Winning his confidence with reassurance and good explanation makes him more recep- tive to treatment. The reactions from radiotherapy in the treatment of all types of cancer are similar. Radiation sickness is a frequent reaction, usually occurring a few days after treatment is begun. There may be only nausea, but more often there is nausea and vomiting ac- Companied by lassitude and, at times, prostration. Because a high caloric, high protein diet is important during radiotherapy, fre- quent small ſeedings are most easily tolerated. Medications used to Control the reaction are vitamin B, sedatives and Dramamine. When radiation is directed to the abdomen or pelvis, diarrhea may occur. Medications such as bismuth or paregoric may be ordered. The diet for such a patient should be bland. X-ray, radium and radioactive phosphorus usually bring about fairly severe local reactions depending upon the dosage, the tolerance of the person and the amount of skin and mucosa involved. Mucous membranes become sensitive and tender about the tenth day after treatment is begun and, when such structures 1 Brown, pages 104-112. NEOPLASTIC DISEASE 45 as the nasal, intraoral, or pharyngeal lesions are radiated, eating and drinking are painſul, the sense of smell is affected and taste may be greatly diminished or changed. Irrigations of the oral cavity and the use of Nupercainal lozenges before mealtime lessen pain and allow the patient to eat with greater comfort. Normal skin undergoes changes similar to that of a degree of a thermal burn. The term “burn” should not be used because it Connotes an accident. The erythema which results is an expected reaction. Other reactions are epilation, itching, burning and moist der- matitis. Before the first treatment is begun, the skin should be bathed with soap and water and any applications of ointment should be removed. In addition, it should be cleansed with ether and/or alcohol. Ointments usually contain metal which will produce secondary radiations and add to the damage caused by the radia- tion itself. The patient is instructed not to bathe the skin where radiation is applied because heat is applied while bathing. This intensifies the action of x-ray, causing a more severe reaction than should occur. He should be cautioned to avoid any form of light or heat therapy unless it has been specifically ordered by the doctor. Skin reactions usually begin about the tenth day after treatment is started. During the course of treatment, the skin should be kept dry and should not be bathed with soap and/or water. Starch powder allays itching, and blistered areas may be bathed with a weak solution of flavine covered with a dressing of gauze soaked in crude cod liver oil and held in place with a bandage. Clothing should be loose and the bed patient should be encouraged not to lie on the skin which is being ir- radiated. When the course of radiation is complete, the skin should be kept as dry as possible by dusting with a powder made up of equal parts of zinc oxide, zinc oleostearate and starch. The crusts formed by the repeated applications of powder will peel off spontaneously, usually leaving the skin completely healed aſter about six weeks. Discharge of the Patient. During the entire period of hos- pitalization of the patient, the nurse should keep in mind his eventual discharge. The nurse must be aware of teaching oppor- tunities and must make use of them during her relationship with the patient and his family in order to anticipate future needs by an active program of health teaching. Frequently, she will recognize the need for additional technical and supportive care beyond that which the ſamily can give, such as the need for a 46 THE FUNDAMENTALS OF SURGICAL NURSING social worker or a nurse in the home. The patient may wish a practical nurse or a private duty nurse but, aſter discharge, addi- tional care can be best provided by referral to the public health nurse. It is wise that the nurse who is going to care for him at home meets him before he leaves the hospital to establish rapport and to learn his needs. Information concerning his care should be explained by the surgeon and nurse at the hospital to provide for continuous care. Follow-up Care. No patient should leave the hospital without having a clear understanding of follow-up care. The nurse should understand the importance of follow-up, for a cancer patient must continue periodic checkups for his entire lifetime. The care of the terminal patient cannot be sharply differentiated from other care required by cancer patients. The facilities and service for care should be closely coordinated with those available for the treatment of cancer patients. The rate of terminal care pa- tients is approximately one to every four annual cancer deaths. This type of care is most frequently provided for in the home. There are many patients who remain in the home during their entire illness because they preſer to do so. In general, however, about 80 per cent will die in a hospital, having remained at home, on an average, ſor over half of their terminal care. At present, beds are not sufficiently available and hospital and re- lated institutional facilities cannot be provided to care ade- quately for all advanced cancer patients. Much work is being done in the study of specific needs of Communities to provide necessary services for all long-term illnesses. The majority of pa- tients are in the older age group; therefore, good nursing requires the application of principles used in the care of older people. The open lesions, drainage and odors so commonly thought to be present in terminal cancer occur in less than halſ the patients. When they do occur, adequate medical attention and good nurs- ing care control them. The fear of pain and the fear of becoming a burden are the emotions which are most common in the pa- tient. Keeping him ambulatory, encouraging occupational ther- apy, reassuring him by careful attention to his questions all serve to promote a relative peace of mind. The bed patient frequently becomes depressed, is uncomfort- able and expresses the desire not to be disturbed. The nurse should give due weight to his requests but should, nevertheless, carry out nursing care which will ensure the greatest amount of Comfort for that day and for the days to come. The most common NEOPLASTIC DISEASE 47 complications which may develop are decubitus ulcers, hemor- rhage, foul odors, starvation and pathologic fractures. Intensive nursing care is necessary to prevent and combat these. Studies have shown that, on an average, nursing care is re- quired for four hours daily to meet the minimum needs of the patient. In addition, studies have shown that better nursing care reduces the amount of medication necessary for comfort. The complaint of pain should never be ignored, but careful examina- tion with evaluation often indicates a method of therapy whereby the use of narcotics at that particular time may be avoided. Palliative measures such as x-ray therapy, gastrostomy, colos- tomy, chordotomy and hormones are used to improve the gen- eral Condition of the patients. The improvement, although tem- porary, is almost spectacular at times, especially, when pain has been relieved. When there is no relief of discomfort, these meas- ures may seem unnecessary or even cruel, yet it is possible that tomorrow may bring a means of cure. SUMMARY Cancer is one of the most common afflictions of mankind. The nurse takes part in the program to educate the public to recog- nize the symptoms of cancer and to seek treatment at once. When treated early by surgery and/or radiation, many patients with can- cer are Cured; unfortunately, the disease is so insidious in onset that it may become incurable before symptoms occur. Even in the late stages, much can be done by skilful nursing to increase com- fort and lighten despair. VOCABULARY REVIEW neoplasm malignant radiotherapy carcinoma metastasis erythema S0.7°CO7770. cachexia palliation benign biopsy SUGGESTED READING 1. Best, Nelliana: Radio Therapy and the Nurse. Am. J. Nursing, 50:140–143 (March) 1950. 2. Boeker, Elisabeth H., and Peterson, Rosalie I.: Nursing Care of Patients with Advanced Cancer. Pub. Health Nursing, 44:463-466 (August) 1952. 3. Cameron, Charles S.: Professional Attitudes and Terminal Care. Public Health Rep., 67:955–959 (October) 1952. 4. Corrigan, K. E.: Use of Radioactive Isotopes. Am. J. Nursing, 48:309-310 (May) 1948. 48 THE FUNDAMENTALS OF SURGICAL NURSING 5 . Goodman, Joseph I: Nutrition in the Treatment of the Chronically Ill. Am. J. Nursing, 51: 165–166 (May) 1951. 6. Kaiser, Raymond F.: Cancer Control in the United States. Public Health Rep., 67:877–882 (September) 1952. 7. Ochsner, Alton: Care of the Cancer Patient. After He Returns Home. J.A.M.A., 137:1582–1583 (August 28) 1948. 8. Pendergrass, Eugene: What to Do for the Cancer Patient When He Re- turns Home. J.A.M.A., 137:1585–1586 (August) 1948. 9. Peterson, Rosalie I., and Soller, Genevieve R.: Nursing Referral of Patients: A Proposed Two-way Referral Form. Pub. Health Nursing, 43.628–630 (November) 1951. 10. Steiner, Paul D.: An Evaluation of the Cancer Problem. Cancer Research, 12:455-464 (July) 1952. 11. Sutherland, Arthur: Psychological Impact of Cancer Surgery. Public Health Rep., 67: 1139–1143 (November) 1952. 12. The American College of Surgeons: Cancer Is Curable: A Symposium. Los Angeles, October, 1948. 13. Thomas, Addie: Typical Patient and Family Attitudes. Public Health Rep., 67:960–962 (October) 1952. CHAPTER 5 Nutrition and Water Balance The surgical patient is not “that appendectomy on Ward A,” but is a human being, all of whose biological needs must be con- sidered. Human metabolism, a complex process under normal conditions, is further complicated by illness and the treatment thereoſ. To provide ſor the daily output of energy and to make the ever-necessary replacement of worn-out tissue cells, the body requires a constant supply of fuel, which is ordinarily derived from the diet. Although a large proportion of surgical patients, particularly those entering the hospital ſor elective operation or because of accidental injuries, do not suffer from metabolic im- balance, there remain many in whom the existing disturbance is equal in importance to the surgical problem. The surgeon is most often confronted with acute or chronic starvation due to ob- struction of some portion of the gastrointestinal tract. Dehydra- tion, deficient protein in the circulating blood (hypoprotein- emia), chemical imbalance due to the loss of chloride, sodium, potassium or other electrolytes from the body may occur. NUTRITION AND WATER BALANCE 49 FLUID BALANCE CHART 'é NAME John 5rnith HISTORY WARD Halstad 5 SERVICE Jorg/ca/ NUMBER fº |NTAKE OUTPUT DATE TIME FLUID (AMOUNT TIME | FLUID AMOUNT 7/7 9am, Walter Ay Aed ſooo co 6-9 am. Walter.|400 cc 7am. |Voided 350cc ſo am. |}}}# 200cc Aer intravenovo // am. |6/ocose |/000cc (0/5 am.1%mitus|| 4-oo co /2 2.7. 5ovo |/oo CC /am. Water by Aed ſooo co 9-/em. Water | 200cc /27 |Voided |450cc 2-am "ɺlzoocc 6 p.m. lvater Áy bed /000 cc /-6 p.m. |Mater |200 cc 7/27 || 7e a 200 cc 6/om. Morded 250 cc. ^er in trave novs 8/om. @ſocose ſooo.cc 7:30pm. Vomitus|300 cc /0,277 97%:/oacc 6 a.m. water by bed! /000 cc 6-6 a.m. water |400cc //pm ||6ided 400cc -—-º- ( total/ Movth |zoooccleoča / |Urine |/45 occ ) tota/ | I. V. ooocol total lºomitus|| 700cc *=ºm \ total/ſ/nºake|4000cc total Output 2/5 Occ N- FIGURE 20. Fluid balance chart of patient on fourth day following operation for perforated appendix with peritonitis. |MAINTENANCE OF METABOLIC BALANCE It is only by careful study and measurement of the actual in- take and output that the status of the nutritional and water bal- ance of a given patient may be determined; to do this accurately requires facilities and a period of time not usually available. Fortunately, however, certain readily performed clinical tests furnish data from which a workable evaluation of the patient's status may be obtained. Chemical analysis of a sample of blood will show gross deficiencies of protein or electrolytes; changes from the normal values do not ordinarily appear until the body stores are badly depleted, but either shock or severe hemorrhage may cause temporary alterations. When the kidneys are not damaged by disease, and in the absence of shock or severe hemor- rhage which may cause temporary suppression of urine, the 50 THE FUNDAMENTALS OF SURGICAL NURSING amount and concentration of the urine excreted are a sensitive indicator of the state of hydration of the patient. As a guide to treatment, the surgeon must know the intake and output of patients whom he suspects of imbalance or threatened imbalance. The duty of measuring and recording the amounts is ordinarily a part of the nursing care. A sample chart for record- ing these data is shown in Figure 20. In the case of a patient who is vomiting, the surgeon can see at a glance the exact amount of fluid intake, and balance this against the urine excreted and the total vomitus, not forgetting to add the insensible loss (respira- tion and perspiration), which is ordinarily assumed to average 11% liters in every twenty-four hour period. The amount of fluid necessary to make up a deficit is thus easily calculated. For those patients who cannot or should not take fluids and food by mouth, several alternative methods of supplying these necessities are available. Tube-feeding. Tube-feeding (gavage) is useful when there is simple inability to swallow, as in the case of unconscious neuro- surgical patients. It is possible to administer complete dietary and fluid requirements by this route, although the material must be sufficiently fluid to pass through the tube. The ingredients and composition for a suggested tube feeding containing the daily requirements for an adult are: eggs 200 gm. glucose 150 gm. evaporated milk 600 cc. orange juice 200 cc. cream 14 per cent 150 cc. brewers' yeast 7 gm. powdered skim milk 50 gm. strained beef 100 gm. applesauce 100 gm, Two essential precautions must be emphasized: the greatest care must be taken to make certain that the tube is in the stomach and not in the trachea, and an individual feeding must be lim- ited to 500 cc. or less. Larger amounts may cause vomiting, which could be as disastrous for an unconscious patient as pour- ing the feeding into the trachea; giving the patient 200 cc. of tube ſeeding every four hours lessens the tendency toward disten- tion and vomiting. Parenteral Administration of Fluids. This is the introduction of fluids into the body through routes other than the gastro- intestinal tract. The fluid used in this type of treatment must be sterile, and must not be harmful to the tissues with which it comes into contact by virtue of either its physical properties or its chemical components. The kind of fluid used varies not only NUTRITION AND WATER BALANCE 51 Injection in other I 14|Nºtes if nocossary ******** * ~ *-ºs \\ WITTÜſiſſimº & --~~ ...tº º 23-Y] ſº - 2 %2. W. N. S 3% º %żą=3; Rºs ſº …” NSS \\ - §=% Šs- FIGURE 21. Apparatus for hypodermoclysis. with the route by which it is given but also with the therapeutic effect desired. Subcutaneous Administration. Water, salt, and glucose are absorbed well when introduced by inſusion into the subcutane- ous tissues (hypodermoclysis). The anterolateral aspects of the thighs or the subpectoral regions are the best sites for such in- fusions, since the subcutaneous tissue there is loosely organized and will take up large quantities of fluid. Upwards of 2 liters in twenty-four hours may be absorbed from a properly given in- fusion. Physiologic saline solution and a 5 per cent glucose solu- tion are tolerated best. The apparatus consists of a flask, rubber tubing, adapter, and 18 gauge needle, all of which must, of 52 THE FUNDAMENTALS OF SURGICAL NURSING course, be sterile and chemically clean. It is advisable to regulate the ſlow of solution into the tissues by the height of the flask above the needle. This rate will vary from patient to patient, but a height of 20 to 30 inches will usually suffice to infuse the fluid into the tissues at the optimal rate of absorption, about 100 cc. per hour. Other essential precautions are the careful disinfection of the skin at the site of injection, the avoidance of injury to important structures in inserting the needle, the application of sterile dress- ings, and adequate fixation of the needle. A needle improperly placed in the subpectoral region may penetrate the chest wall with puncture of the lung, or with introduction of fluid into the pleural cavity followed by collapse of the lung. The continuance of an infusion after twenty-ſour hours increases the possibility of infection entering along the needle tract, and it is therefore ad- visable to start a new infusion in a new location should further ſluid be necessary. There is always some discomfort at the site of the infusion, and in some patients the pain is intolerable, constituting one of the chief disadvantages of this form of ther- apy. This discomfort may be minimized by avoiding overdisten- tion of the tissues with fluid. The addition of an enzyme, hya- luronidase, to the solutions has been found to promote more rapid absorption of the fluid by the tissues. Peritoneal Administration. Physiologic saline solution, with or without 5 per cent glucose, is sometimes injected into the peritoneal cavity. Under normal conditions fluid is well absorbed by the peritoneum, but this method is almost entirely limited to inſants with thin abdominal walls. Since the hazard of punctur- ing intestine or bladder is considerable, the use of intraperitoneal injection should be limited to certain inſants in whom other routes are not ſeasible. Intravenous Administration. The parenteral route of ſluid administration used most widely at present is intravenous in- fusion (venoclysis). This method for introducing needed sub- stances into the body has been one of the most valuable means of improving surgical results since the development of asepsis. A prime requisite is the ability to insert a hollow needle into a vein without unduly damaging the vein. Although it was once looked upon as a difficult procedure, with a little practice the technic is simple. In many hospitals intravenous therapy has already been delegated to the nursing staff. Although the actual administra- tion of an intravenous infusion is simple, great care must be NUTRITION AND WATER BALANCE 53 Solut, on Air ~3. entrance ir entrance Adhesive ClO3U re | FIGURE 22. Apparatus for venoclysis. The splint straps must be tight enough to hold the arm, but not to occlude the veins or rubber tubing. taken in the preparation of the apparatus and the fluids to be used, as well as in the choice and amount of fluid and the rate of injection. Attention to certain details will facilitate the technic of in- travenous therapy. An 18 or 20 gauge needle with a sharp point but short bevel is the most satisfactory, but smaller needles must be used ſor small veins even though the rate of flow will be slower. The use of a splint to immobilize the arm or leg is im- portant, since in that way the needle will not be dislodged by a sudden movement on the part of the patient. The injection of bubbles of air must be avoided, as serious or even fatal air em- bolism might result (see Chap. 15). The apparatus need consist only of a flask, pure rubber or cellophane tubing into which a visible-drip tube has been interpolated, and an adapter to fit the 54 THE FUNDAMENTALS OF SURGICAL NURSING needle (Fig. 22). This simplification of apparatus is important since it has been amply shown that many of the febrile reactions which formerly followed intravenous infusions were due to fail- ures to clean the apparatus. Small particles of dirt or lint or blood, even though sterilized, may act as pyrogens (ſever pro- ducers). In the preparation of the set, simple washing is not sufficient; the component parts must be chemically clean. Solu- tions and containers must be chemically pure and sterile. In order to take the special precautions necessary to prevent febrile reactions it has been found advisable in most hospitals to estab- lish a central unit for the preparation of the intravenous outfits and fluids. Other hospitals make a practice of purchasing fluids and intravenous sets already prepared. Some of these use plastic or cellophane tubing, which is to be used only once. Following each use the apparatus must be completely dis- mantled. The rubber tubing is boiled three to five minutes in I per cent sodium bicarbonate solution, rinsed thoroughly in hot water, then rinsed in freshly distilled water. Glassware is placed in a rack where it is dipped in boiling 4 per cent sodium triphos- phate solution, then dipped in boiling water. Hot water followed by freshly distilled water is then circulated through each piece by means of suction. The set is reassembled and checked for any par- ticle of any kind in the tubing by examination under fluorescent light. Tubing which has lost its elasticity should be replaced. It is essential to prepare all new rubber tubing before using, because of the sulfur content. A good method is to run hot sodium hydroxide solution through the tubing ſor one-half hour, followed by 1 per cent acetic acid for neutralization. The tubing is then washed in hot tap water, and hot tap water is run through the tubing for one hour. Finally, freshly distilled water is run through the tubing. Disregard of the proper cleaning and prep- aration of the sets will be followed by reactions. The fluids commonly used in intravenous therapy include whole blood, plasma, saline and glucose solutions in various Con- centrations, solutions of protein hydrolysates, and certain thera- peutic agents which may be dissolved in water or added to the above solutions. It is possible to use hypertonic (concentrated) Solutions in intravenous therapy without damaging tissues, be- cause the chemicals, if injected slowly, are rapidly diluted in the flowing blood stream, but care must be taken lest the wall of the vein be damaged or the solution be spilled outside the vein; oc- clusion of the vein or tissue necrosis may follow these accidents. NUTRITION AND WATER BALANCE 55 It is unnecessary to warm these solutions before using them; in fact they may be used as taken directly from the refrigerator. There is indeed some danger in applying heat to such solutions since one or more of the chemical constituents may be altered. The choice of the fluid, the amount to be given, and the rate of administration depend upon the need of the individual patient, and are naturally the surgeon's responsibility. Just as in any type of treatment, the nurse should ask for exact directions. It should be borne in mind that intravenous fluids given too rapidly or in too large amounts may seriously embarrass the circulation, caus- ing heart failure; these precautions are particularly important ſor the aged and for those who may already have heart disease. The rate of flow is measured in drops per minute, and is Con- trolled by a thumb-screw clamp on the tubing. Authorities differ somewhat as to the rate of flow that is advisable, but Ordinarily there is no advantage in speed. If the circulating blood is loaded with additional fluid too rapidly, the excess will be quickly secreted by the kidneys and much of the value of the treatment may be lost. In the treatment of hemorrhage, where the imme- diate restoration of the total blood volume is important, rapid injection may be advisable. Among the advantages of the intravenous method of fluid ad- ministration are the inherent efficiency, the relative freedom from pain, the means of adding to the blood volume quickly, and the wide variety of substances which can be used. The disadvantages include the necessity for careful preparation of equipment and fluids, occasional difficulty in performing venipuncture, and the danger of circulatory embarrassment. It is now possible to main- tain a patient in metabolic balance by intravenous therapy alone ſor short periods of time. Continuous Intravenous Drip; Use of Canmula. When the con- dition of the patient necessitates Continuous and exacting regula- tion of intravenous fluids, the Surgeon may place a cannula or a polyethylene tube into the vein because of the difficulty in keep- ing a needle in position. It is convenient to have the necessary equipment assembled and autoclaved in readiness. A satisfactory Set includes a cannula, knife blade and handle, hemostats, mouse- tooth forceps, iris Scissors, iris forceps, towel clips, fine intestinal needles threaded with black silk, No. 25 x 5% hypodermic needle, 2 cc. Luer Syringe, 20 cc. Luer syringe, medicine glass, gauze sponges, 2 inch bandage and sterile adhesive tape. Polyethylene tubing is available in sizes which accommodate various gauges of 56 THE FUNDAMENTALS OF SURGICAL NURSING intravenous cannulae. Soaking new tubing in aqueous solution of benzalkonium chloride solution 1: 1000 for eighteen hours is a satisfactory method of sterilization. A suitable vein is exposed through a small incision. An opening is made into the vein, about 10 cm. of tubing is introduced into the vein and a ligature is applied about the vein and tubing. The tubing is then fastened to the extremity with sterile adhesive tape. This is done because there is some tendency for the streaming current of fluid and blood to draw the tubing entirely into the vein. The intravenous cannula is then fitted into the tubing. Splinting the extremity is useful and, with careful attention, the venoclysis may be Con- tinued for several days. SUMMARY One of the factors contributing to the safety of modern surgery is the recognition of the entire needs of the individual patient. Deficiencies of water, salt, and other chemical Constituents of the body may occur as the result of disease or incident to surgery; these deficiencies must be prevented or overcome. When a pa- tient cannot take fluids or food by mouth, water and other essen- tial chemicals must be administered by other routes. VOCABULARY REVIEW metabolism parenteral cannula dehydration hypodermoclysis venipuncture electrolyte venoclysis glucose gavage pyrogen SUGGESTED READING 1. Bayles, Spencer, and Ebaugh, Franklin G.: Emotional Factors in Eating and Obesity. J. Am. Dietet. A., 26:480–431 (June) 1950. 2. Cooper, Lenna F., Barber, Edith M., and Mitchell, Helen S.: Nutrition in Health and Disease. 11th Ed. Philadelphia, J. B. Lippincott Co., 1950, pp. 68–116. 3. Dericks, Virginia C.: Measuring and Recording Oral Fluid Intake. Am. J. Nursing, 47:319–320 (May) 1947. 4. Elman, Robert: Fluid Balance from the Nurse's Point of View. Am. J. Nurs- ing, 49:222–224 (April) 1949. 5. Elman, Robert, and Weichselbaum, T. E.; Pre- and Postoperative Parenteral Maintenance of Electrolyte Balance with Salt Mixture Containing Sodium. Potassium, Chloride and Phosphate. Ann. Surg., 135:145–288 (February) 1952. 6. Gentry, Martha E., and Swanson, Florence L.: A Psychological Aspect to Weight Control. Am. J. Nursing, 52:849–850 (July) 1952. 7. Lloyd, Ruth E.: Integrating Nutrition and Diet Therapy. Am. J. Nursing, 51:473–476 (July) 1951. CHAPTER 6 Hemorrhage and Shock HEMORRHAGE Blood is normally contained within the walls of the arteries, the veins, and the capillaries, escaping only when an opening is made in one of these. This abnormal escape of blood, or bleeding, constitutes a hemorrhage, and the size of the hemorrhage—that is, the amount of blood lost—depends upon the circumstances of the bleeding. Arterial bleeding is characterized by the forceful spurt- ing of bright red blood; blood escaping from a vein is darker, and flows out with less force but often with equal rapidity; capil- lary bleeding is less rapid than either of these, with a relatively slow oozing of bright red blood. The kind and size of hole in the vessel wall, the number of vessels opened, and the patient's blood pressure influence the rate of blood loss. Bleeding in association with an open wound is usually external, but internal bleeding is fairly common as a result of penetrating wounds or subcutaneous injuries, and is incidental to certain abnormal conditions produced by disease. An internal hemor- rhage may occur in any of the body cavities or organs, and recog- nition of such a concealed hemorrhage is difficult. The coagulat- ing mechanism is altered in vitamin K deficiency and in hemo- philia. In addition, there are other diseases in which there is a tendency to spontaneous hemorrhage or to prolonged bleeding: these include the leukemias, purpura, and sickle cell anemia. Thus, before performing an operation, it is important to discover whether the patient has a tendency to bleed abnormally, for not only must proper precautions be taken, but this additional haz- ard must be duly weighed in considering the advisability of at- tempting operation. Mechanism. There is scarcely an aspect of surgery which has received more attention and study than hemorrhage, and still there remains much to be learned. Nevertheless, the following points seem established: As blood is lost the body makes a great effort to compensate for this loss. Storage depots of blood in the spleen and the bone marrow are called upon, and fluid is drawn 57 58 THE FUNDAMENTALS OF SURGICAL NURSING from the tissues; the vessels contract, and the heart pumps faster in an effort to make a smaller volume of blood perform the necessary tasks of supplying oxygen and other nutrition to the Cells and removing carbon dioxide and other wastes. As the hem- orrhage continues, a critical point is reached at which the total volume of the circulating blood is so reduced that the mechanics of the pumping system ſail, and the Oxygen-carrying capac- ity of the blood is insufficient. Investigators are not yet agreed as to what factor plays the chief part in the ultimate col- lapse, and it is probable that it is the result of the combined action of all of them. Whether a patient can withstand a hemor- rhage depends upon the portion of his total blood volume which has been lost, upon the rate of loss, and upon his ability to com- pensate for loss. Thus, a large healthy person might successfully stand the slow loss of a considerable amount of blood, whereas a small debilitated person might not survive a rapid loss of only a Small amount. Symptoms and Signs. Patients who are bleeding severely com- plain of faintness, giddiness, and thirst. They are restless and pale, and breathe with increasing rapidity and depth, as though hungering for more air. The body temperature may fall a degree or two below normal while the pulse increases in rate though diminishing in force. A sudden increase in pulse rate is oſten the first sign of concealed bleeding. If the bleeding remains un- checked the blood pressure falls rapidly and the pulse at the wrist becomes imperceptible. At this point the bleeding may cease be- cause the low blood pressure permits clotting of the blood, thus closing the opening in the vessel, and the patient may rally; or the hemorrhage may have exhausted the reserve of the patient So that, despite Cessation of bleeding, he becomes comatose and dies. Trecitment of Hemorrhage The first step in treating hemorrhage is to stop the bleeding (hemostasis). Before discussing surgical methods employed in hemostasis it is well to consider the wonderful protective mechan- ism for this purpose with which the human body is endowed. Blood has the property of coagulating, forming a firm adherent mass or clot which iſ undisturbed will occlude an opening in a vessel. Except under unusual circumstances blood does not clot while circulating in the vessels; but when it has escaped into a HEMORRHAGE AND SHOCK 59 wound the necessary reaction takes place. Coagulation normally requires only three or four minutes. If the bleeding is so free and rapid that the escaping blood is quickly washed out of the wound there is at first no chance for coagulation; later, as the blood pres- sure falls and the rate of flow lessens, clotting may occur with resultant cessation of bleeding. When arteries or veins are di- vided completely, coagulation is favored because the open end of the vessel both retracts and contracts from the action of the elastic tissue in its wall; the more dangerous bleeding is usually associated with a partly divided vessel, when retraction is im- possible. It is beyond the scope of this work to consider the theories of coagulation and the details of its Complex mechanism, but interference with the normal functioning of this mechanism is of great importance in Surgery. Administration of Vitamin K. Deficiency of vitamin K results in altered coagulation, a condition commonly encountered in the newborn and in patients with biliary duct obstruction. In these instances the clotting may be brought to normal by administra- tion of the vitamin either parenterally or by mouth, in which latter case bile salts must be taken as well in order to promote absorption of the vitamin from the intestine. Electrocoagulation. Hemophilia is another Condition in which severe or often fatal hemorrhage occurs as a result of failure of the blood to coagulate. Fortunately not very common, this dis- ease is confined to the male sex, and is hereditary, the bleeding tendency being transmitted only by the female. There appears to be a congenital absence of some essential factor in the co- agulation process, and thus far modern science has not supplied the missing substance. Electrocoagulation with high frequency cautery has proved the most valuable means of controlling hemo- philic bleeding. Methods of Arresting Hemorrhages. Hemostasis—that is, the prevention of loss of blood by the control of bleeding—is essential in surgery; nevertheless, the most skilful surgeon may suddenly be confronted with dangerous bleeding in the course of an opera- tion. Then, too, hemorrhage may result from a postoperative mishap or inſection, or from disease, or may be caused by an ac- cidental injury. The prompt control of bleeding saves lives; but although speed is essential, haste is dangerous, for ill-considered measures may not only ſail of their purpose but may actually damage important structures or introduce infection. The means 60 THE FUNDAMENTALS OF SURGICAL NURSING FIGURE 23. Clamping a vessel by a hemostat. to be employed depend upon the exigencies of the situation, and range from the deliberate and direct application of a fine artery forceps (hemostat) to the use of the bare fingers. The prime Con- sideration is to bring about the occlusion of the bleeding vessel. During the course of an operation the surgeon may temporarily control bleeding by the application of hemostats, by the use of a tourniquet on an extremity, by manual pressure, or by packing with gauze; but at the end of the procedure the divided vessels must be occluded by ligature or suture, although capillary oozing from a large surface may be treated by packing. Tourniquet. When hemorrhage occurs outside of the operating room, elsewhere in the hospital, on the street, or in the home, the liſe of the patient may depend upon the ability of the bystanders to render first aid. Bleeding from an injured arm or leg may be controlled by the application of a tourniquet; but in every in- stance the tourniquet must be applied above the elbow or the knee, closer to the trunk than the wound, and tightly enough to stop bleeding. A tourniquet placed below the elbow or the knee will not occlude the vessels which lie between the two bones of the forearm or the leg. If not sufficiently tight, a tourniquet will Constrict only the veins, thus serving to encourage bleeding. Soft rubber tubing makes an ideal tourniquet, but in an emer- gency anything that can be used to constrict the extremity will do—a handkerchief, a stocking, or a belt. Studies have shown that HEMORRFIAGE AND SHOCK 61 s Šs – // f =2% s S. Š-2 % ~< 5s N - Sºſs-º: * ~2% ~ NS , Sist--ºssº 22 |S$ * *s. S: S; Ré2 \s S- E2 ~S SST º sº-, S; * —2 SS WNY- º --- * Š s N D >2% § 03 FIGURE 24. An emergency tourniquet. narrow tourniquets are less damaging to tissue than wide ones, and that tight tourniquets, properly applied, may be left in place for several hours without fear of injuring the tissues which are temporarily deprived of circulation. Manual Compression. Manual compression of large arteries which run superficially may serve to check bleeding, especially in wounds of the head and neck (Fig. 25). When the emergency is extreme it is far better to plunge one's fingers into a wound than to watch the patient bleed to death. Internal Hemorrhage. Conservative Treatment. The treatment of internal hemorrhage, such as that from an ulcer of the stomach, is of particular importance. In general, two courses of action are open, conservative treatment or operation. Conservative treat- ment is selected for those patients in whom operation is inad- visable, or when it seems likely that the hemorrhage may not be prolonged. The patient is kept in a quiet room, with the foot of the bed elevated. Sedatives are given, and often an ice-cap is placed on the affected region. Food and fluid by mouth are with- held, as are parenteral ſluids, since it is not desirable to stimulate the intestinal tract, and since a low blood pressure favors coagula- tion at the site of the hemorrhage. In many instances the bleed- 62 THE FUNDAMENTALS OF SURGICAL NURSING :* § *** * * * * * * * * * *Temporal A. Femoral A....]...ſ. FIGURE 25. Points at which the application of digital pressure will suppress bleeding from large arteries. ing ceases spontaneously, and the patient may then receive fluid and transfusions; but when the bleeding continues to a dangerous degree, immediate blood transfusions may be necessary. Operative Treatment. If it seems obvious that the patient is bleeding rapidly from a source which is accessible to surgical intervention, operative treatment is advisable. For such contin- gencies a large amount of blood is held available for transfusion (blood bank), a rapid operative procedure is carried out with a view to checking the bleeding immediately; when that has been done large transfusions are given to replace the blood which the patient has lost. HEMORRHAGE AND SHOCK 63 Blood Transfusions. The best agent for Counteracting the systemic effects of hemorrhage is whole blood. The idea of infus- ing new vigor into a sick person by introducing the blood of a healthy person is an old one, but transfusion has been practically possible only since the beginning of this century. The problems involved are three: the compatibility of the donor's blood with that of the recipient; the prevention of coagulation during trans- fer; and the exclusion of bacterial and other contamination. Blood Groups. Human beings are divided into four groups on the basis of blood compatibility, Groups O, A, B, and AB. (No known animal blood is compatible with that of human beings.) These groups are differentiated by the specific reaction of the blood serum of the members of each group upon the red Cells of the members of other groups. BLOOD TYPING AND CROSS-MATCHING. The test to distinguish blood types is simple. A centrifuge is used to separate the red cells from the serum, and a few red cells suspended in normal saline solution are added to a drop of known Group A serum, and a few to a drop of known Group B serum. These preparations are examined under the microscope for agglutination (forming Clus- ters of cells). The red cells of Group O are not agglutinated by either serum, those of Group AB are agglutinated by both, whereas those of Group A are agglutinated only by the B serum, those of Group B only by the A serum. This test is known as grouping. In preparing for a transfusion the blood of the pros- pective recipient is typed; then his serum and red cells are cross. matched with those of a prospective donor of the same group. If there is no agglutination or hemolysis (dissolution of red cells) the matching is satisfactory, and the donor's blood is suitable for that recipient. Rh Factor. Despite careful cross-matching a number of serious reactions were observed after transfusion, particularly after mul- tiple transfusions, although the donor's blood was thought to be Compatible and had previously been given successfully to the patient. This mishap may now be prevented. Studies made in the past few years have shown that the blood of most people (about 85 per cent) possesses a substance known as the Rh factor. These persons are considered Rh positive, and those who do not have it are Rh negative. Rh positive blood may be safely administered only once to an Rh negative recipient, because the Rh negative individual is thereby sensitized to the Rh factor. A second Rh 64 THE FUNDAMENTALS OF SURGICAL NURSING FIGURE 26. Drawing blood from the donor in indirect transfusion. positive transfusion to an Rh negative recipient is likely to cause serious or even fatal reaction. The Rh factor, in common with the other factors of blood grouping, is an inherited characteristic. An interesting and most important effect of this is the sensitization of an Rh negative mother by the blood of an Rh positive fetus, so that the first transfusion from the necessarily Rh positive husband and father might result in serious consequences. The agglutination pro- duced in this reaction is delayed, and is observed only after the cross-matching has been incubated for several hours. The safest procedure at present is to use only Rh negative donors for Rh negative recipients, unless it is known that the contemplated transfusion is the recipient's first, and that the latter, if a woman, has never been pregnant. Methods of Transfusion. The problem of transferring the blood from donor to recipient is managed in two different ways: the so-called indirect method in which an anticoagulant is added to the blood as it is drawn from the donor; and the direct method in which the transfer of blood is carried out so rapidly HEMORREHAGE AND SHOCK 65 that coagulation does not occur. There are advantages and dis- advantages in both methods, but the advantages of the indirect method make it the general choice. INDIRECT TRANSFUSION. The apparatus needed is the same as that for an intravenous infusion with the addition of a needle and tubing for drawing the blood into the flask. Similar precau- tions as to sterility and cleanliness are necessary. An amount of an anticoagulant (usually 5 per cent sodium citrate) sufficient to pre- vent clotting is first drawn into the flask; then the desired amount of blood is taken from the donor's vein and the flask is gently agitated to ensure mixing of the blood with the citrate solution. The flask may then be sealed and stored, or the blood may be given at once, just as any intravenous treatment is given. It is unnecessary to warm blood before injecting it even though it has been taken directly from the ice box; in fact, there is danger of altering the blood if heat is applied. The chief advantages of the indirect method are: (1) the blood may be stored, thus making a large supply of blood available for immediate use; (2) the blood may be administered rapidly or slowly as dictated by the need of the patient; (3) it is unnecessary to keep donors on hand, waiting for an emergency; and (4) the whole transfusion can be managed by a single worker. DIRECT TRANSFUSION. There are several technics for performing direct transfusion, but one of the simplest is the multiple syringe method. This requires at least three workers, patient and donor must be on adjacent stretchers, and the apparatus needed consists of needles, three-way stopcocks, and about a dozen 20 or 30 cc. Luer Syringes. A venipuncture is performed on both donor and recipient; one worker then draws a syringeſul of blood, detaches the syringe from the stopcock, and hands it to a second worker who injects the blood directly into the recipient. The third worker receives the used syringes, washes them in sterile physiologic saline solu- tion, and thus prepares them for the first worker. In this way the transfer is accomplished before the blood can coagulate. The advantages of the method are that no special apparatus or Solutions are required, and that the blood is unchanged in any way. Disadvantages include the need for a team of trained work- ers, the undesirability of having the donor or donors on hand or in the operating room, and the necessity for speed, which means that the blood cannot be given slowly. 66 THE FUNDAMENTALS OF SURGICAL NURSING ºf ſ\\ Y º Qiaº Ti S-ºº-sº FIGURE 27. Direct transfusion by the multiple syringe method. The whole pro cedure is carried on with aseptic technic. Blood Banks. The value of a large store of blood which is ready for immediate use is obvious. Thousands of lives were saved in World War II because an improved technic of handling and stor- ing blood had been developed. Blood for a bank may be ob- tained from the relatives or friends of patients, or from volun- teer donors. Care is taken that the blood drawn for the bank, as for all transfusions, comes from healthy nonsyphilitic, non- malarious donors. In addition, the donor must be carefully ques- tioned concerning recent attacks of jaundice or other symptoms suggestive of hepatitis. The blood is collected in flasks containing citrate solution, and these, after being sealed and properly labeled HEMORRPHAGE AND SHOCK 67 as to group, are stored in a special refrigerator at 35° F. By adding fresh blood as the bank is drawn upon, a constant supply is maintained, and in an emergency blood can be had for a patient as soon as the matching can be performed, which is a matter of minutes. There is deterioration of the red blood cells aſter a few days, however, and if the blood has not been used in two weeks the red cells are discarded. The plasma (blood from which the red cells have been removed) can then be kept ſor a long time, provided, of course, that there is no bac- terial contamination. Plasma can be dried, after which it can be stored indefinitely; it is ready for use when dissolved in the proper amount of sterile distilled water. In some banks plasma to be stored is frozen; it is thawed immediately before use. SHOCK This term serves to designate a state of collapse from which the patient may not recover unless prompt measures are taken. The clinical appearance of the profoundly shocked patient is not difficult to recognize, but incipient shock is often not detected. This is unfortunate, for here as in many other conditions, early treatment is far more successful than late. At times the onset of shock is abrupt; but often it may be recognized by a slight ac- celeration of pulse rate, by a small drop in the systolic blood pressure, or by the patient's sudden restlessness or complaint of uneasiness. In a late stage the severely shocked patient is apa- thetic, his respirations are shallow or sighing, and the pulse is rapid, ſeeble, and disappearing in quality. The skin is moist, pallid, even cyanotic, and the body temperature falls. The blood pressure is low, often so low that it cannot be recorded. Ordinary fainting (syncope) resembles shock in some ways, particularly in the sudden collapse with loss of consciousness and fall in blood pressure. This condition is apparently due to a sud- den circulatory Collapse resulting from nervous stimulation and differs from shock in being quickly reversible. Most patients re- cover completely following the simple procedure of lowering the head. Although the clinical condition of shock has been recognized for a long time, it was the experience in caring for wounded sol- diers in the war of 1914–1918 which led to the serious investiga- tion of this condition, an investigation which is still being vigor- ously prosecuted. As a result of these studies it has become appar- 68 THE FUNDAMENTALS OF SURGICAL NURSING ent that shock is caused in many ways—by severe trauma, hemor- rhage, burning, prolonged anesthesia, and others. Interestingly enough, shock develops as a result of many conditions which are not surgical, some of which are pneumonia, Coronary thrombosis, and hyperinsulinism. A practical way to consider shock is to realize that any circumstances or diseases which cause a person's death may in the same way cause shock, which is, aſter all, the ultimate stage of living. There are many observable alterations in the physiology of the shock patient, and it is not yet certain which of them are causes and which are effects; all are closely related, and each helps the others to ſorm a vicious circle from which it is difficult to extricate the dying patient. Trecitment of Shock Improvement in the treatment of shock has not kept abreast of the volume of experimental study of the condition, and the best treatment is still prevention. Through adequate study of each patient before operation, the proper measures can be taken to see that he is in the best possible condition. The loss of blood and of other body ſluids should be kept to a minimum, and any loss of significance must be promptly replaced before the loss plays a part in producing shock. Obviously, it is not possible in every instance to prevent shock, particularly when the condition develops as the result of an accident or other injury. When shock is present it must be treated vigorously by every means available. Care must be taken to remove the causes or to lessen their effects, as by splinting fractures to prevent further trauma, checking bleeding, or relieving pain. Circulatory stimu- lants are indicated, such as caffeine, epinephrine, ephedrine, Coramine, Levophed, and the like, but may not help materially. Transfusions of large amounts of blood constitute the best treat- ment when reduction of the circulating blood volume is the predominating cause. When blood is not immediately available, the intravenous injection of plasma or of dextran solution may be of temporary benefit. The patient should be placed in a tilted bed, with feet elevated, so as to ſavor circulation to the brain, and careful attention paid to his airway, in order to aid respira- tory exchange as much as possible. Treatment with oxygen may be helpful. It must be constantly borne in mind that a shocked patient may reach a certain critical point in his downward course aſter which no therapeutic measures will successfully break the HEMORRHAGE AND SHOCK 69 º ZT-4-2ſ Fº Z2 # S)z = #I =º ss FIGURE 28. Arrangement of equipment in shock therapy. vicious circle of changes and death will be inevitable; hence the need for prompt recognition and immediate treatment. SUMMARY Bleeding is always serious; the rapid loss of considerable blood may be lethal. The nurse must recognize external hemorrhage and the signs of internal bleeding and know what to do imme- diately. Blood is the best replacement for blood lost. Shock is a dangerous condition produced by serious hemorrhage and by injury or disease. Measures undertaken to combat shock are successful only when begun early. VOCABULARY REVIEW hemorrhage tourniquet hemolysis coagulation transfusion Rh factor hemophilia agglutination plasma SUGGESTED READING 1. Blalock, Alfred: Principles of Surgical Care: Shock and Other Problems. St. Louis, C. V. Mosby Co., 1940. 70 THE FUNDAMENTALS OF SURGICAL NURSING 2. Brown, Ivan W., Jr.: Present Status of the Rh Factor. Am. J. Nursing, 48:14– 17 (January) 1948. 3. Cecil, Russell L., and Loeb, Robert F.: A Textbook of Medicine. 8th Ed. Philadelphia, W. B. Saunders Co., 1951, pp. 1211–1214. 4. Christopher, Frederick: A Textbook of Surgery. 5th Ed, Philadelphia, W. B. Saunders Co., 1949, pp. 13–17. 5. Kirby, Charles: The Clinical Use of Blood and Blood Derivatives. Am. J. Nursing, 50:88–90 (February) 1950. 6. Lam, Conrad R.: What Is Shock? Am. J. Nursing, 51:116-117 (February) 1951. CHAPTER 7 Preparing the Patient for Operation On entering the hospital the patient finds himself in a new world. He is confronted with strange sights, sounds, and smells which, if they do not actually frighten him, at least do not add to his peace of mind. The necessary preoperative examinations, the drawing of blood, or the questions of the house surgeon may shake his confidence by suggesting that his condition is not yet well understood. Furthermore, few patients anticipate an opera- tion with pleasure, though many are resigned or conceal their true feeling. Children do not hide their honest terror, and it is well to realize that many adults experience the same emotion be: neath an apparently calm exterior. To explain away the strange- ness, to maintain the confidence of the patient in his surgeon, to encourage and support, are duties of both the nurse and the surgeon; but these duties will fall largely to the nurse since she will be constantly with the patient. Routine Preoperative Examination. A complete survey of the patient's physical condition must be made before operation, not only for the purpose of establishing the proper diagnosis, but also to avoid unnecessary complications. An acute respiratory infec. tion or a recent exposure to such an infection warrants postpone. ment of all but emergency procedures. Such systemic disorders as diabetes mellitus, heart disease, and nephritis must be discov- ered so that the proper measures may be taken. As has been PREPARING THE PATIENT FOR OPERATION 71 stated, dehydration and dietary deficiencies must be corrected. Study of the patient's blood is made with particular reference to possible anemia or alteration of coagulation. It is obvious that the discovery of any abnormality other than that for which the operation has been proposed calls for reconsideration of the whole situation, and may necessitate a change in the plan for the patient. Hygiene. Since the presence of bacteria on the patient's skin is a source of wound contamination, the personal cleanliness of the patient is important. The number of bacteria on the skin may be reduced by a thorough bath the evening before operation and by freshly laundered clothing. Long hair of women should be plaited into two braids. The hair of all patients is covered with a muslin cap either in the ward or on arrival in the operating room. This is done for protection and cleanliness. The value of adequate rest is obvious, and except in an emer- gency the patient should have a night of sound sleep before operation. To secure this rest often necessitates the use of seda- tives, the most useful of which are the barbiturates. Shaving. The skin of the operative field must be shaved before operation. The exact area to be shaved will depend on the nature of the operation and the custom of the surgeon. In general, it is better to shave too large an area than too small. Hair prevents adequate skin disinfection, may act as a foreign body if caught in a wound, and adds to the discomfort caused by removing dress- Ings. The area should be shaved carefully with a sharp razor; the general direction for drawing the razor should be the one in which the hair naturally inclines. It is often necessary to go over the area two or three times in order to remove all hair. In order to avoid misunderstanding, the nurse in charge of preparing a patient will do well to ask for specific shaving instructions, even to the marking of the area to be shaved. Preparation for Anesthesia. In the matter of preparation a distinction may be made between those patients who are to have general or spinal anesthesia and those who are to have local in- filtration anesthesia. For the last-mentioned, unless an extensive procedure is planned, the preparations already described are sufficient. All other patients should be sent to the operating room with the stomach as nearly empty as possible. The im- Portance of this point cannot be exaggerated. It is nearly impos. 72 THE FUNDAMENTALS OF SURGICAL NURSING Thorocotomy \ * . A\ Y P iſ ||-- f A. Axillo ond cloviclz to ont. Sup. Spline P. Axillo ond neck to lumbor region FIGURE 29. Preoperative shaving in thoracic surgery. Axilla ond &rm below clbow A. Jew line to anterior spine P. Hoir line to lumbor region are FIGURE 30. Preoperative shaving in radical mastectomy. PREPARING THE PATIENT FOR OPERATION 73 Loporotomy From nipple line indui; pubic region FIGURE 31. Preoperative shaving in abdominal surgery. Nephrectomy §s.” \ > ,- | | \, … % || A \ſ P \ \{ A\s P. Axilla and lower Scopuk to buttock A. Axillo and nipple line to upper publs FIGURE 32. Preoperative shaving in kidney surgery. 74 THE FUNDAMENTALS OF SURGICAL NURSING Laminectomy ZCervical: hoir linz §§§§§ to lower Scopulo. % ÇS ** * * v-S Šºš *:::::::::: º: % SCôpulo. OW2 e... ... " (š. \lmboſ”: IOWQI’ º ribs to gluteo- femoral fold S. Q})^*}^X.2% & §§§º FIGURE 33. Preoperative shaving in spinal surgery. sible to induce anesthesia smoothly when the stomach is full, and vomiting will almost always occur with the Consequent dan- gers of aspiration and physical overexertion. Moreover, nausea and vomiting often occur during the period of recovery from anesthesia, and here again the value of an empty stomach is dem- onstrated. The hazard and inconvenience of a full stomach when that organ itself is to be operated upon, scarcely need mention. These patients, therefore, are not permitted to have solid food for at least eight to twelve hours before operation, and should not be allowed to have any liquid, including water, for at least four hours before the induction of anesthesia. It is quite helpful to place signs on the bed showing, in bold-face letters, “Nothing by Mouth”; this serves as a reminder to personnel who may not realize that the patient is being prepared for operation. Patients who, as a result of their condition, may not be deprived of fluids during this period should receive the necessary fluids by paren- teral routes. At times, especially with obstructions of the stomach or intestinal tract, it is necessary to pass a tube into the stomach in order to make sure that it is empty. In most hospitals routine preoperative orders specify that food and fluids be withheld; but the vigilant cooperation of the nurse is needed, as patients not PREPARING THE PATIENT FOR OPERATION 75 &5 &Left hond ot wrist IILoft foot %Right patollar region FIGURE 34. Preoperative shaving in surgery of the extremities. Umbilicol line to mediol thigh Lumbor region to mediol thigh FIGURE 35. Preoperative shaving in perineal surgery. 76 THE FUNDAMENTALS OF SURGICAL NURSING confined to bed may thoughtlessly or designedly search for and obtain water while waiting for operation. One of the most indelible impressions carried away by many surgical patients of former years was the early awakening on the morning of operation by the arrival of the nurse or attendant armed with the paraphernalia of the ritual enema. The value of emptying the colon and rectum immediately before attempting surgical procedures on these structures cannot be denied; but in most other cases the preoperative enema is unnecessary, or at least should be given the night before operation. Preanesthetic Medication. The Comfort of the patient, the task of the anesthetist, and the hazard of operation may all be favor. ably influenced by the intelligent use of certain drugs. The value of sedatives to ensure adequate rest before operation has been mentioned; when these are given, particularly the more powerful and long-acting barbiturate derivatives, the patient should not be permitted to get out of bed, and the nursing staff should so arrange matters that he is disturbed as little as possible until called to the operating room. A tropine. Atropine is given to patients who are to undergo gen eral anesthesia. The average adult should receive 0.6 mg. of atropine sulfate by hypodermic injection about twenty minutes before anesthesia is induced. By this means the secretion of saliva and mucus is reduced, leaving the mouth and the air passages dry. Absorption of the anesthetic agent is thus favored and the hazard of aspiration lessened. During long operations it is some- times necessary to repeat the dose of atropine in order to main- tain a dry airway. Scopolamine. In recent years many anesthetists have come to prefer scopolamine in place of atropine. They believe that this drug does not render the bronchial secretions quite so viscid as does atropine, thus lessening the likelihood of the formation of the mucous plugs which cause pulmonary atelectasis (collapse of the lung). Scopolamine, in addition, produces in many patients a definite sense of well-being (euphoria), which adds to the ease of anesthetization. The usual dose of this drug, in the form of hyoscine hydrobromide, is 0.3 mg. for the average adult. Morphine. The use of morphine in preparing the patient for Operation is routine, whether the procedure is to be done under general or regional anesthesia. Because morphine has a powerſul depressing action in respiration, small doses (8 or 10 mg.) are PREPARING THE PATIENT FOR OPERATION 77 given if general anesthesia is to be used; the effect accomplished will be to quiet the patient, allay fear, and render induction of anesthesia easier. When local anesthesia is contemplated, how- ever, larger doses (12 or 16 mg.) are indicated because of the effectiveness of morphine in relieving or dulling pain. Care of Valuables. All loose articles such as jewelry, hairpins, eye-glasses, and false teeth must be removed and placed in safe- keeping. This is done not only to prevent damage or loss of these articles, but also to safeguard the patient from the hazard of aspirating loose dental appliances. Rings which cannot be re- moved easily, or when there is objection to their removal, may be left on the fingers; in either event a narrow tape is tied to the ring and fastened securely around the wrist, care being taken not to obstruct the circulation. The nurse should always try to per- suade the patient to remove all rings except the wedding band. Valuables, such as a pocket watch or a wallet containing several dollars, are often kept at the bedside of the patient. Unless the nurse specifically asks the patient concerning his valuables before he goes to the operating room, he will most likely forget about them because of anxiety and apprehension of the forthcoming operation. The nurse should assume the responsibility for these valuables. A safe way to care for them is by placing them in an envelope made of heavy paper, with spaces for the patient's name, the name of the nurse who takes the valuables, and the patient's signature when the valuables are returned. The envelope should be placed in the hospital vault or a place especially prepared for this purpose by the hospital. Legal Consent. The surgeon must obtain the consent of the pa- tient before anesthesia is induced or operation is performed. In Some states verbal consent is sufficient; but much better protec- tion is afforded the surgeon and the hospital if an operative per- mit is signed by the patient or his guardian. It is the nurse's re- sponsibility to see that this important legal formality has not been overlooked. Final Preparation. When the patient awakens on the morning of operation, he is usually anxious and apprehensive. Making him understand that those who care for him are genuinely inter- ested in him will build up confidence. This may, in part, be accomplished by carefully explaining in a calm and reassuring manner the details of the care given him. It is usual for the fam- ily to visit the patient before he goes to the operating room. The 78 THE FUNDAMENTALS OF SURGICAL, NURSING FIGURE 36. Envelope for patient's valuables. feeling of dependency, mingled with fear of the unknown, make both patient and relatives especially alert and sensitive at this time to the way in which the nurse and other personnel take care of him. Every consideration shown fosters confidence, pleas- ant associations and Cooperation. In ordinary circumstances, the nurse knows the time that the patient is scheduled for operation. She is, therefore, able to make a plan so that his care can be car- PREPARING THE PATIENT FOR OPERATION 79 ried out calmly and efficiently and so that, at the same time, the needs of other patients can be met. The nurse must not lose sight of the importance that this event has for the individual patient even though she has taken care of innumerable other preopera- tive patients. She should guard against giving the impression that this is just another patient. The latter should be made to feel that, because his nurse has taken care of many patients, he is fortunate to have an experienced nurse with a deep interest in him. Just before going to the operating room there are certain de- tails of care which are essential. For the comfort and Convenience of both patient and surgeon, it is always important to make cer- tain that the patient has voided just before leaving the ward. The patient is clothed in long cotton flannel boots and short Cotton flannel gown, open in the back. A sufficient number of blankets should be used to avoid undue exposure of the patient while he is wheeled through draughty corridors, but care must be taken not to use so many covers that he is made to perspire. In some hospitals the clinical record is taken to the operating room by the nurse who accompanies the patient; in others an attendant from the operating room collects all charts the first thing in the morning. The nurse should review the clinical chart to see that it is complete before it is sent to the operating room. The patient is finally taken to the operating room in his bed or on a previously prepared stretcher. In most instances, the family is not permitted to go to the operating room but exceptions, at times, must be made when those who take care of the patient think it advisable. While accompanying a patient to the operating room, the nurse should try to do all she can to prevent tension. Preventing the orderly from wheeling the stretcher too rapidly, carefully guiding the stretcher so that the elevator is entered with ease and talking only to the patient, except when directions are necessary, will demonstrate to the patient that he has the full attention and interest of the nurse; these are essential for good supportive care. The nurse must not leave the patient until the anesthetist has obtained from her the patient's name, the preoperative medica- tion, and the exact time it was given; when the anesthetist as- sumes charge of the patient, the nurse may return to the ward. It is desirable to close the door of the anesthesia room in order to protect the patient from the noises in the corridor, the con- 80 THE FUNDAMENTALS OF SURGICAL NURSING *ś Nºſy &\\Fº G (; º FIGURE 37. The administration of general anesthesia. Note suction equipment (A); soda lime absorber (B); breathing bag (C); conductive soles (D); and grounding wire to reduce explosion hazard (E). versations and, also, ſrom seeing the transportation of operating room equipment. All of these things seem routine to the nurse but, to the patient, these may actually cause terror. It is during the last few moments before anesthesia is induced that many patients are most in need of reassurance, an essential service which must be rendered intelligently and faithfully. SUMMARY In preparing a patient ſor operation, the concept of caring for the entire individual is again emphasized. The operative area is shaved, but the psychologic preparation of the patient is far more important. Careful stock is taken of the physical condition of the patient and proper medication is given. Legal obligations such as consent to operation and care of valuables must not be overlooked. A good nurse brings to the operating room a con- fident, calm patient. POSTOPERATIVE NURSING CARE 8] VOCABULARY REVIEW atropine scopolamine morphine hyoscine hydrobromide SUGGESTED READING 1. Coller, Frederick A., and DeWeese, Marion S.: Preoperative and Postopera- tive Care. J.A.M.A., 137:455–461 (November 5) 1949. 2. Mason, Robert L., and Zintel, Harold A.: Preoperative and Postoperative Treatment. Philadelphia, W. B. Saunders Co., 1947. 3. Meehan, Rose: Understanding the Preoperative. Am. J. Nursing, 42:1289– 1290 (November) 1942. 4. Krause, Marie V.: Nutrition and Diet Therapy in Relation to Nursing. Philadelphia, W. B. Saunders Co., 1952, pp. 222–223. CHAPTER 8 Posfoperative Nursing Care Patients who have had minor procedures under local anesthesia ordinarily do not require special care, but all others, particularly those who have had general anesthesia, must have constant nurs- ing attention until they are ſully conscious. In some hospitals, it is still the custom to return the patient to the ward or to his room immediately after operation, where he receives care from a nurse employed by him or assigned to him for this special duty. Other hospitals, however, have established a recovery room or ward equipped and staffed ſor the particular purpose of render- ing special care to patients during the immediate postoperative period. The advantages of this latter method are many. RECOVERY ROOM Under ideal conditions, the recovery room is located on the same floor as the operating room suite and should, if possible, actually be one of the units of that suite. The size of the recovery room depends upon the daily load of the operating room. The most satisfactory arrangement is the unit designed for the accom- modation of ſour patients; this is the number of patients which can be most efficiently cared for by one nurse. Multiples of this 3 : i § ,-, 9 g * 215 NURSES STATION STORAGE | § r:-- OPERATING ROOM CORR IDOR . . . . . . . . . . . . . . . .R …I.F.- : * >, >, >, >, >T-Tº-I...". • ...::::::::::::::::::::"... º.º. . . . . . ."...'...'...'. *.*.*.*.*.*.*. . . . . . . . . . . . *.*.*.*.*.*.*. . . . . . . . . ... "... *.*.* .....…": " : "... • . . . . . . .” -------. ". . . . . . . . . . .". -:-". . ." ." *—- tº------>e's ºr * *** ** TO WAlTING ROOM 2-1 18 22× UTILITY ROOM § 25 _f 33-r-, § 24 GP2 9 27 “Bes 284) FIGURE 38. Recovery room. (See legend below.) POSTOPERATIVE NURSING CARE 83 | i i . . i § ! | i | i | : | — i unit can be used when larger numbers of patients are to be cared for. At the conclusion of an operative procedure carried out under general anesthe- sia, the still unconscious pa- tient is carefully transferred to a stretcher and wheeled by the anesthesiologist di- rectly to the recovery room. The stretcher used is spe- cially equipped for the proper positioning of the patient, and has adjustable sides to prevent the patient from falling. Poles can be at- tached to hold the ſlasks of blood or intravenous fluids, and the wheels of the stretcher can be locked sol- idly. The patient remains on the stretcher during his stay in the recovery room. The stretcher is wheeled into one of the specially prepared spaces; immediately at hand are oxygen equipment,” suc- tion apparatus, mouth gag,' tongue forceps, and airway (breathing tube). Also avail- able is the equipment for measuring the patient's blood pressure. In conveni- ent cupboards are stored drugs, solutions, dressings, pillows, basins, linen, such emergency items as sterile ; 1 See Brown, pages 119–150. : *: 84 THE FUNDAMENTALS OF SURGICAL NURSING 2. º FIGURE 39. Recovering from anesthesia. A, suction; B, sphygmomanometer; C, oxygen; D, intravenous fluids. sets for perſorming tracheotomy and intravenous cut-downs, and other sterile supplies such as syringes, needles, intravenous equip- ment and the like. The anesthesiologist delivers the postoperative orders, as well as the patient, to the recovery room nurse and the latter then as- sumes responsibility for the care of the patient. ROUTINE CARE DURING RECOVERY FROM ANESTHESIA The stuporous or partly conscious patient is unable to help himself effectively; indeed, he may even add to his difficulties by involuntary or ill-controlled movement during the period of rest- lessness and confusion which occurs as he awakes. As the patient eliminates the anesthetic agent from his body he passes through the same stages as during induction, but in reverse order. Muscle POSTOPERATIVE NURSING CARE 85 NAME John. 2miń. VVARD Halifted 3 DATE 19 — HOURS MEDICINE_AND| Nourishment RENAARKS ACP. Jo az. onconscious A with much in throat. Aace flushed hoé and moist c/ean Wasal tube connected to //200 cc . FIGURE 40. Postoperative chart (bedside notes) following operation for per- forated appendix with peritonitis. 86 THE FUNDAMENTALS OF SURGICAL NURSING tone and reflexes are regained; and at this time painful sensation from the operative wound may stimulate the patient, causing restlessness or other poorly coordinated movement. Unless care- fully guarded, he may roll out of bed or may pull off his dress- ings. Nausea and vomiting are of frequent occurrence, and it will require the utmost vigilance and skill on the part of the nurse to prevent aspiration of vomitus and soiling of the dress- ings or bedclothing. The nurse must be able to determine accurately the state of consciousness of the patient. The appearance of involuntary mo- tion and swallowing or blinking presage a return to conscious- ness. So, too, does response to painful stimulus; as, for example, groaning or moving when strong pressure is made by the finger between the ribs. In many instances the patient's sense of aware- ness can be aroused quickly by informing him that he has had his operation. When he registers surprise it is evident that he is becoming more alert. A patient is not fully conscious, however, until he responds promptly to his name, answers questions Co- herently and correctly, and performs coordinated movements in response to definite requests. It is only when the patient is fully conscious that the nurse may safely leave the bedside. Bedside Notes. During the recovery period the nurse must carry out simultaneously three assignments: the observation of the patient, the performance of necessary treatments, and the recording of both. To be observed are the character and rate of the respiration and pulse, the behavior of the patient, and the condition of the operative field. Treatment includes maintenance of adequate respiratory exchange, maintenance of the patient in the desired position, protection of the operative field, medication as ordered, assistance with transfusions or other procedures undertaken by a house surgeon, and reassurance of the patient. An accurate and up-to-the-minute record is kept on a suitable chart so that the surgeon may determine at a glance the Condition of his patient. Maintenance of Respiration. The student nurse who would learn how to ſacilitate the breathing of an unconscious patient should first observe someone who is sleeping naturally. She will note that such a person breathes regularly, slowly, and deeply. The color is good, and the respiration is quiet and seemingly effortless. Assuming that the person under observation is lying on his back, it will be seen that his mouth opens and his jaw drops as muscular relaxation accompanies deepening sleep. At POSTOPERATIVE NURSING CARE 87 Il FIGURE 41. Position recommended for the patient recovering from general anes thesia. Note that head and mouth are dependent. the same time the muscles of the soft palate relax, and the quiet breathing becomes a noisy snoring. There is now partial obstruc- tion to free breathing, and it is apparent that the person is mak- ing more effort, chiefly on inspiration. In addition, the tongue may fall back and overlie the upper opening of the larynx (glot- tis), thus effectively blocking the ingress of air. When this occurs a loud snoring inspiration is suddenly cut short, and the sleeper makes a forceful inspiratory effort, accompanied by congestion or even cyanosis of the head and neck. It is as though he was sud- denly being choked; that, of course, is exactly what has hap- pened, although the obstruction to the passage of air is internal and due to displacement of the relaxed tongue. The stimulation caused by this choking awakens the sleeper, who then shifts his position. A patient, however, under the influence of an anesthetic which has relaxed his muscles and paralyzed his reflexes, does not awake, nor can he change his position but will die of asphyxia unless quickly aided. The student nurse will also note that unanesthetized patients who sleep on the side or the abdomen, so that the face is inclined downward, are able to sleep deeply without snoring or other evidence of respiratory obstruction. The ideal position, therefore, for the patient during recovery from anesthesia is the lateral or, better still, the prone position, one arm and shoulder elevated, face to the side and down as illustrated in Figure 41. Obviously, this position also facilitates the drainage of vomitus, mucus, or blood from the mouth and nose, whereas the unconscious patient lying face up on his back will certainly aspirate any fluid that collects in his mouth. The nature and the location of the surgical procedure often prevent the use of the prone position, but only rarely is it impossible to place the patient on his side, or at least to turn the head to the side. 88 THE FUNDAMENTALS OF SURGICAL NURSING ſ ~ *tº Rubber airwey º W \ \º –2 s |) ) ) *\ ſ * , ->z ºr == 2. oº::= § A/ / ºr og as: §º ſ =º s---sf \ sº - sº-s FIGURE 45. A, Oxygen tent; B, patient receiving oxygen through BLB mask. that portion of the lung supplied by the obstructed bronchus is the result, because the air remaining in the alveoli of the Ob- structed segment is rapidly carried away by the circulating blood. As a result of disease, injury, or operation, an opening (fistula) may form between a bronchus and the pleural cavity, or between a bronchus and the external chest wall. In the first instance a closed pneumothorax, of the tension variety, is a result. In the Second case, air is inspired and exhaled through the external opening at every breath. It is to be remembered that some pathogenic bacteria are con- stantly present in the respiratory tract; they are sucked into the lungs with each inspiration. An almost inevitable consequence of atelectasis or fistula, therefore, is infection. Roentgenography; Oxygen Therapy. No introductory discus- sion of the respiratory system would be complete without the mention of roentgenography and oxygen therapy. The diagnosis of pulmonary lesions has become marvelously accurate as a re- sult of the use of x-rays; by making successive films the surgeon 106 NURSING IN THORACIC SURGERY is able to study the progress of the patient in a manner far su perior to that afforded by physical diagnosis. The use of oxygen, whether administered by mask or by tent, has saved innumerable patients in whom the vital capacity was so reduced that ordinary air Could not supply amounts of oxygen adequate for Saturation of the circulating blood." SUMMARY The movement of air into and out of the lungs is essential to life. Impairment of this function because of disease or injury results in respiratory embarrassment leading, if severe, to asphyxia. Openings in the chest walls, leaks in the lung or bronchi, and obstruction to the latter are dangerous. Oxygen therapy is life-saving. VOCABULARY REVIEW vital capacity atelectasis mediastinum tidal air asphyxia oxygen pneumothorax bronchus SUGGESTED READING 1. Cooper, Lenna, Barber, Edith M., and Mitchell, Helen S.: Nutrition in Health and Disease. 11th Ed. Philadelphia, J. B. Lippincott Co., 1950, pp. 288-289; 490–494. 2. Christie, Arthur C.: Mass Screening Techniques for Chest Diseases. J.A.M.A., 151:114–117 (January 10) 1953. 3. Lacy, Marvin, and Hitchock, Marie Owen: Retained Secretions Following Thoracic Surgery. Am. J. Nursing, 51:607-609 (October) 1951. 4. Poppe, J. Karl, and James, Ruby B.: Intratracheal Suctioning. Am. J. Nursing, 45:538–540 (July) 1945. CHAPTER II Thoracic Injuries The majority of thoracic injuries respond readily to simple, conservative treatment. Injuries to the chest are of grave sig. nificance only when disturbance of the respiration is caused, when serious hemorrhage occurs, or when the element of inſec- tion is introduced. Severe chest wounds are likely to be com- 1 See Brown, pages 119-150. THORACIC INJURIES 107 plicated by all of these factors. Simple contusions, abrasions, and lacerations of the chest wall which do not involve the deeper structures are treated just as are those occurring elsewhere about the body, and do not merit special Consideration. BLUNT FORCE INJURIES Fracture of one or more ribs is the usual Consequence of a heavy blow or fall upon the chest. Broken ribs constitute a very painſul injury, but are not in themselves serious. Such fractures heal readily, and the only treatment necessary Consists in meas- ures to relieve the pain which accompanies each respiratory movement. Splinting of the injured area by means of adhesive strapping, or preſerably by the use of a Snug bandage of an elastic material such as stockinet, will minimize the movements of the bone ends and thus relieve the pain. Morphine or other marcotics may also be given, provided the patient's respirations are not depressed, and it is certain that the signs of other injury will not be masked by the effect of the narcotic agent. Puncture of the lung or tearing of the intercostal blood vessels oſten accompanies the fracture of a rib, the injury being caused by the momentary displacement inward of the jagged bone end. It is highly important, therefore, to realize that severe intra- thoracic damage may complicate a blow upon the chest, even though there is little external evidence of violence. When such damage occurs, the treatment is the same as for penetrating wounds of the chest. A far more serious and often fatal type of injury follows severe compression of the chest. This injury may be produced by crushing, as in a mine cave-in, or by the blast of a nearby ex- plosion. Great numbers of the lung alveoli and capillaries are ruptured by the sudden terrific squeezing of the chest. For this accident, rest and the administration of oxygen are the best treatment. The internal damage is often so extensive, however, that death quickly follows from a combination of hemorrhage and asphyxiation. PENETRATING WOUNDS In civil life the chest wall is penetrated in various ways, usually by a revolver bullet, a knife, or an ice pick. Such wounds are occasionally self-inflicted, but are seldom accidental in the or- dinary sense of that word. The relatively low mortality rate oc- curring in these injuries in civil life is not necessarily a tribute 108 NURSING IN THORACIC SURGERY to the skill of the surgeon; it is an index to the widespread lack of accurate anatomical knowledge and the lack of accurate aim ing in the heat of attack. In war, penetrating wounds of the Chest are followed by a ſar higher mortality rate, due, no doubt, to the frequent occurrence of multiple wounds (e.g., those caused by machine guns and high explosives), to the occurrence of large wounds (such as those from high explosives and bayonets), to the accuracy of aim which practice brings, and to the unfortu. nately unavoidable delay in Securing surgical aid. t Any wound which has penetrated the skun of the chest wall, or, for that matter, the skin of the adjacent neck or abdomen, should be suspected of being a penetrating wound and must be treated as such until the wound is absolutely proved to be nonpenetrat. ing. It is astonishing how much internal damage can be accom. plished through a tiny, innocent appearing, external wound. The examiner may readily peer into the depths of a large wound and see that the chest wall has been penetrated, or he may hear air passing in and out (sucking wound), or he may ſeel the charac- teristic crepitation of air bubbles which have been forced into the deeper tissues by the respiratory movements (subcutaneous emphysema); but simple examination of the wound which has none of these characteristics will not serve to prove nonpenetra- tion. The color of the patient, the character and rate of respira tion, the pulse rate, the blood pressure level, and the percussion and auscultation of the chest are as important Considerations as inspection of the wound, for careful observation of these will afford a means of gauging the nature and extent of an intra- thoracic injury when one is present. When circumstances and the Condition of the patient permit, accurate information may be secured by fluoroscopy. Treatment. The proper treatment for a penetrating wound of the chest consists in adequate disinfection and closure of the wound, administration of tetanus antitoxin, or tetanus toxoid iſ the patient has been previously immunized, and careful observa- tion of the patient's progress. If his general condition remains good, with adequate maintenance of blood pressure level and no respiratory distress, no additional immediate treatment is neces. sary other than rest in bed. Sucking wounds must be closed without delay, or, if too large for closure, the opening must be quickly packed with an airtight dressing so that the open pneumothorax is converted at once into a closed pneumothorax. THORACIC INJURIES 109 In nearly every patient who has received a penetrating chest wound, there is hemopneumothorax (air and blood in the pleural sac). When the signs of rapid and progressive hemorrhage are apparent, simple treatment will not suffice, and it is necessary to open the chest at once (thoracotomy). The source of the bleed- ing must be ſound, the bleeding checked, and the blood which has been lost must be replaced by adequate transfusion. In most patients, fortunately, the bleeding will not be so severe; recovery is aided by prompt and repeated aspiration of the blood from the pleural cavity. This procedure (thoracentesis), carried out by inserting a needle through the chest wall between two ribs, is necessary so that the blood will be removed before it clots and thus permanently compresses the lung. If the hemothorax has already clotted, the clot can be liquefied by the use of the enzymes streptokinase and streptodornase, which have the power to liquefy fibrin. In cases of neglected or unsuccessfully treated hemothorax, it still may be possible to achieve expansion of the compressed and constricted lung by an operation (decortication) in which the lung is exposed and the old, organized clot peeled off. Complications. Since bacteria are present in the lungs, and since they may also be introduced through the wound, infection is a Irequent complication. The resulting infectious process does not differ greatly from other types of empyema thoracis, and its treatment is, in general, the same as for the other types (Chap. 12). Infection is suspected when a rise in temperature and an increased leukocyte count are noted, usually forty-eight to sev- enty-two hours after injury. The diagnosis is made by examining and culturing fluid obtained from the chest by aspiration with a needle (thoracentesis). Wounds of the heart are not infrequent in penetrating wounds of the chest. The diagnosis and treatment of these are discussed in Chapter 17. DIAPHRAGMATIC HERNIA The diaphragm serves as the dividing wall between the thor- acic and abdominal cavities. Ordinarily, there are openings only for the passage of the esophagus, the aorta, the vena cava, lym- phatics and nerves. Abnormal openings may result from develop. mental failure during ſetal life, or can be produced by injury or inſection. Such an abnormal opening or defect in the diaphragm Will permit abdominal contents (stomach, Omentum, Colon, small 1 10 NURSING IN THORACIC SURGERY intestine) to enter the thoracic cavity. Iſ the opening is large there may be serious compression of the lung, interfering with respiratory function just as does a pneumothorax. Other symp- toms, particularly those of intestinal obstruction, may result from the displacement and twisting of the abdominal organs involved. Operative treatment is required to relieve the symptoms and save life. Repair of a diaphragmatic hernia includes replacement of the abdominal organs and closure of the defect in the dia- phragm. The procedure is tolerated well even by the newborn inſants. Nursing care is given as after any thoracotomy; usually the patient will also be treated with continuous gastric suction to prevent abdominal distention (see p. 243). NURSiNG CARE The patient who has a thoracic injury usually is admitted through the emergency room. It is desirable to place him near the nurses' station to facilitate close observation and care. If it is the patient's first admission to a hospital he may not only be frightened by his pain and condition but also by his new surroundings. His family must be notified and asked to come to the hospital. The nurse should give explanations and answer questions in a calm and reassuring manner to try to reduce the anxiety and apprehension which usually exist in both patient and family. The temperature, pulse, respirations and blood pressure should be taken as soon as he has been made comfortable in bed. Rest, quiet and the control of pain are essential; usually morphine or some other narcotic is ordered. There may be great variation in the appearance of patients with thoracic injuries but the prin- ciples of Care are the same for all; modifications are made ac- Cording to the needs of the patient. Because his condition may change rapidly, the nurse must observe him frequently for change in color or cyanosis, more rapid or weak pulse, difficulty in breathing, subcutaneous emphysema or a drop in blood pres- sure. Any change in the vital signs of the patient should be called to the attention of the surgeon immediately. Routine care given to a patient on admission includes bath- ing the patient but this should be postponed until his condition is fully evaluated and permission is given by the surgeon. Anti- biotics are usually ordered and, when administered to a patient who has been in an accident which invariably makes him dirty, THORACIC INJURIES | 1 || special care should be taken in cleansing the skin before the in- tramuscular injection is given. Usually a liquid diet is permitted and increased to a normal diet according to the patient's toler- ance, but when the patient is very ill, or if there is a question of abdominal injury, fluids and solid food are usually withheld. The patient who has difficulty in breathing is given oxygen. Explaining the value of the oxygen as a means of making him more comfortable before attempting to administer the treatment, and also explaining very simply when the apparatus is applied, lessens apprehension and increases cooperation. A sterile thora- centesis set is kept near the patient in case of sudden need for the aspiration of fluid or air from the chest. During the Convalescence, routine care including good phys- ical care, instruction of good health habits and direction of di- versional and occupational therapy should be given. Learning to know the patient, to develop awareness of his needs and to help him meet them in order to prepare him for a more health- ful life, are criteria of good care. Before discharge, instructions concerning his return visit to the doctor and his home care should be clearly explained and written out for him. SUMMARY Thoracic injuries are always dangerous. Careful observation of the patient will permit early detection of loss of blood or inter- ſerence with respiration. Oxygen therapy and thoracentesis are regularly employed. VOCABULARY REVIEW sucking wound hemopneumothorax decortication subcutaneous diaphragm thoracentesis emphysema thoracotomy SUGGESTED READING 1. Carter, B. Noland, and Giuseffi, Jerome: The Use of Tracheotomy in the Treatment of Crushing Injuries of the Chest. Surg., Gynec. & Obst., 95:55–64 (January) 1953. 2. Christopher, Frederick: A Textbook of Surgery, 5th Ed. Philadelphia, W. B. Saunders Co., 1949, pp. 847-851. 3. Coleman, Frank P.: Traumatic Hemothorax: Decortication in the Treat- ment of the Chronic Infected Type. Arch. Surg., 50:14-18 (January) 1945. 4. Lindsey, Monette: Traumatic Thoracic Surgery. Am. J. Nursing, 44:1029– 1032 (November) 1944. CHAPTER 12 Suppurative Disease of the Lung and Pleura LUNG ABSCESS An abscess in the functioning substance (parenchyma) of the lung presents much the same pathologic appearance as an abscess elsewhere. Preceded by a stage of bacterial invasion, tissue ne- crosis (death) and local resistance combine to produce a Central core of pus surrounded by a wall of inflammatory granulation tissue. Sooner or later the contents of the enlarging abscess cavity rupture into a small bronchus, and as a result of this the patient Coughs persistently, producing large amounts of foul purulent sputum. Despite the constant drainage of pus into the bronchus, an abscess cavity in the lung may show little tendency to collapse and heal, due in large part to the noncollapsible nature of the thoracic wall. As is to be expected, the infectious process causes a systemic response: the patient has ſever and leukocytosis, feels badly, and loses weight. Solitary abscess of the lung occurs, but multiple abscesses are Somewhat more Common. The Causative agent cannot be incrim- inated in every instance, but abscesses are known to ſollow the aspiration of irritating substances (often foreign bodies, such as a peanut, chewing gum, pins) or purulent material from tonsil- lar or dental inſections, and from retained foreign bodies such as bullets, shell fragments, or bits of clothing received in a wound. Lung abscesses are also produced by bacteria carried into the lung by the circulating blood (blood stream inſection, septi- cemia), and by direct extension into the lung of a Suppurative process originating outside the lung. Because of the nature of the bacteria, lung abscesses are usually productive of the ſoulest pus. The putrefactive nature of the inſection is due to the presence of organisms, both aerobic and anaerobic, ordinarily ſound in the mouth; although the mouth bacteria may not be the initial cause of the abscess, as Secondary invaders they soon dominate the picture. 112 SUPPURATIVE DISEASE OF THE LUNG AND PLEURA 113 Nursing Care of Lung Abscess Prevention. As always, the best treatment is prevention. The known incidence of pulmonary abscess following tonsillectomy and dental extraction makes it imperative to prevent aspiration of material from the mouth or pharynx during those procedures. This is best accomplished by placing the patient with head down and feet elevated, and by careful use of the suction apparatus. In fact, aspiration must be guarded against in all patients under- going general anesthesia, and in those unconscious from other C3 UlsCS. General Measures. Clinical experience has shown that about one third of acute pulmonary abscesses heal spontaneously during the first three months. It is wise, therefore, to treat all early, acute cases conservatively, using such measures as rest in bed, amplified diet, transfusion, antibiotics, and postural drainage. The re- mainder of the patients do not improve, but show progression of the lesion. Fever and cough persist, larger amounts of pus are produced, and the patient becomes thin and weak. Early in the disease, examination of the chest reveals the signs of pulmonary consolidation; later there is cavity formation. This is best demon- strated by roentgenography. The chronic stage may last months or years, death finally resulting from hemorrhage (caused by erosion of a pulmonary vessel), extension of the abscess into the pleural space (empyema), or spread of the infection through the blood stream, commonly to the brain. About half of the patients suffering from chronic pulmonary abscess can be cured by surgical means. Coughing. The patient should be encouraged to Cough, and to Continue Coughing, for the bringing up of as much as possible of the pus will empty the abscess cavity, thereby aiding in the Collapse and healing of that cavity. Technic of Postural Drainage. Postural drainage is a most use- ful treatment, but is often poorly understood by nurses and in- effectually carried out by patients. To properly perform it, the patient is positioned so that his head and trachea are dependent and the abscess cavity is uppermost. The exact location of the abscess determines whether the patient must be on his back, chest or side. When the patient is correctly positioned, the pus will have a downhill path from the abscess cavity to the mouth. The purulent material, however, is viscous, and may not flow rapidly; therefore the patient must be made to remain in the proper posi- I 14 NURSING IN THORACIC SURGERY FIGURE 46. Proper positions for postural drainage of pulmonary abscess in right upper lobe (A), left upper lobe (B), right lower lobe (C), and left lower lobe (D). tion ſor twenty to thirty minutes despite his discomfort, and must be encouraged to cough vigorously and ſrequently the while. Morning and evening sessions usually suffice, but more may be required if the output of pus is large. Measuring and Disposal of Pus. The purulent expectoration is naturally highly infective, and patients must be provided with suitable containers so that its proper disposal can be accom- plished. It is important, also, that the twenty-four hour volume be measured, as the progress of the disease may thus be gauged. A graduated waxed cardboard box fitted with a cover is a good container for collection and measurement of the sputum. The ex- pectoration has a very ſoul, nauseating odor and should be re- moved immediately. The best method of disposal is burning. For this purpose sawdust is added to the material and the con- tainer wrapped in several thicknesses of newspaper. Bronchoscopic Examination. The bronchoscope has been widely used in treating pulmonary abscess. This instrument, a SUPPURATIVE DISEASE OF THE LUNG AND PLEURA 115 metal tube equipped with an electric light, can be passed through the mouth and larynx into the trachea, and by means of it the mucous membrane lining the respiratory tract can be inspected as ſar down as the main bronchi. Suction can be used, and many different medicaments have been instilled, but with little suc- cess. Postural drainage properly carried out is far more satisfac- tory. Following bronchoscopic examination the patient may Com- plain of Sore throat and may cough a great deal, but these Com- plaints are temporary. Nursing Care of Patients Having Bronchoscopy. In preparing the patient [or bronchoscopic examination nothing is given by mouth for at least six hours prior to the time of the pro- cedure. This helps prevent vomiting, which would not only in- terſere with the examination but might lead to aspiration. The patient should be told what to expect at examination to prevent apprehension and encourage Cooperation. Before the patient leaves for the examining room, a barbiturate is usually ordered and, in many instances, morphine and/or atropine are also given. False teeth are removed and the patient is transported on a litter or in bed. Either Cocaine or tetracaine hydrochloride is used to anes- thetize the pharynx. These drugs are cerebral stimulants, but in large doses will cause depression of the central nervous system. The sedatives given before examination counteract the stimulat- ing effects of these anesthetic agents and help prevent laryngeal Spasm. Following bronchoscopy, the nurse must observe the patient closely ſor slowed respirations and cyanosis. Giving the patient oxygen through an Oronasal mask is helpful in combating the TeaCtlOI). The patient should be told that he must not take anything by mouth for at least two hours, so that aspiration because of the anesthetized pharynx may be prevented. Surgical Treatment of Lung Abscess. The removal of the dis- eased portion of the lung (segmental resection) is now the safest and most satisfactory method of dealing with lung abscess. In Some instances, this may mean the removal of one lobe (lobec- tomy), and occasionally the removal of the entire lung (pneu- monectomy). The operation, its complications and dangers, and the postoperative care are the same as in the treatment of bron- chiectasis, and are described in the discussion of that condition. 1 16 NURSING IN THORACIC SURGERY In most patients, the result of the removal of the diseased lung is dramatic, with recession of fever, immediate disappearance of cough and sputum, gain in strength and weight, followed by a return to normal life. BRONCHIECTASIS Bronchiectasis is a pathologic condition of the lung charac- terized by progressive enlargement of the tiny bronchioles. There is, in addition, a considerable degree of chronic inflammation of the involved portion of the lung, attributable in part, certainly, to secondary infection. A common complication of other pul- monary diseases, bronchiectasis is often the result of the obstruc- tion to the bronchi that follows the growth of a lung tumor, the enlargement of a lung abscess, or the swelling of tuberculous lymph nodes. Bronchiectasis also occurs as a primary disease, without demonstrable cause. In this primary form of the disease the initial lesions are usually found in the lower lobe of one or both lungs. It is important to realize that primary bronchiectasis is a dis- ease of young people; the onset is usually in the second or third decade of life. The patient notices a chronic hacking cough that is oſten thought at first to be due to “chronic bronchitis”; weeks or months later the Cough becomes productive of increasing amounts of foul smelling sputum. In the early stages most of the sputum is Coughed up in the morning on rising; later, expec- toration is more ſrequent and large in amount. At first there is little systemic disorder, but after months or years, loss of weight, ſever, anemia, and clubbing of the fingers appear. Enlargement of the distal phalanx of the fingers (clubbed ſin- gers) is a curious phenomenon which has been observed since the days of Hippocrates. It is known to occur in association with any form of chronic pulmonary disease, but no adequate explanation has been offered. The clinical diagnosis of bronchiectasis is a difficult one, since the symptoms are so similar to those of pulmonary tuberculosis. Bronchoscopic examination often discloses the bronchus ſrom which the pus is coming, and the introduction of a radiopaque substance (Lipiodol) into the bronchus affords a means of out- lining the enlarged bronchioles on the x-ray film. When un- treated, the disease is slowly progressive, and the patient dies after a few years as the result of hemorrhage or spread of the infection. SUPPURATIVE DISEASE OF THE LUNG AND PLEURA 117 Treatment of Bronchiectosis Until recent times the treatment of bronchiectasis was far from satisfactory. General hygienic measures, change of climate, the eradication of possible ſoci of infection such as infected teeth, tonsils, or sinuses, and bronchoscopic treatments all had exten- sive trial with but indifferent results. Fortunately, however, the development of thoracic surgery has brightened the outlook for those afflicted with this disease. In those patients in whom the process has not spread beyond the lower lobes of either or both lungs, the surgical removal of the affected portions brings about a CUllſe. Segmental Resection. The term segmental resection means the removal of a portion of pulmonary tissue which comprises an anatomic unit, such as an entire lobe, or that portion of a lobe served by a branch of the lobar bronchus. General anesthesia is induced in the usual manner, and then a tracheal tube is inserted, making it possible for the anesthetist to control accurately the oxygenation and inflation of the lungs and to aspirate secretions or blood from the trachea and bronchi. Some surgeons preſer to enter the chest anteriorly, others prefer the posterior approach. Difficulty is encountered if the lung is adherent to the chest wall, as the dissection necessary to free the affected lobe oſten causes brisk bleeding. The branches of the bronchus, pulmonary artery, and pulmonary vein to the dis- eased segment are carefully identified, isolated, and divided. This makes possible the removal of the diseased portion of the lung. Great care must be exercised in closing the bronchial stump, for a leak will result in disaster. It is, of course, necessary to ligate the branches of the pulmonary vessels securely. Before the chest wall is sutured the remaining portion of the lung is inflated by the anesthetist, and, remarkably enough in most instances, the cavity will be nearly filled. A soft rubber catheter is introduced into the chest through a separate, tiny stab wound, and is placed so that its tip lies in the space formerly occupied by the re- moved segment. To prevent the entry of air into the chest, the Outer end of the catheter is securely closed by means of a clamp. The operation is ordinarily performed quickly and without shock, but it is naturally a wise precaution to have blood avail- able. At the conclusion of the procedure the anesthetist aspirates the bronchial tree and removes the tracheal tube. | 18 NURSING IN THORACIC SURGERY of lung Bronchus’ Pulm,"/. FIGURE 47. Lobectomy. The left lower lobe has been removed, the vessels ligated, and the bronchus sutured. Insert shows location of incision. If the disease is bilateral the operation may be attempted on the opposite side about three months later. Nursing Care Following Segmental Resection. In preparation, the following equipment should be assembled: the routine post- operative unit, oxygen therapy equipment and sterile “water seal” suction apparatus. Oxygen therapy is begun immediately and is usually continued for twenty-four to ſorty-eight hours or until the patient breathes easily without increased rate of respira- tIOIlS. Before attaching the chest Catheter to the suction apparatus, as illustrated in Figure 51, the whole system should be tested. Clamping the tubing that leads to the catheter and turning on the suction should produce bubbling of water in bottle 2. Such a suction drainage system withdraws the effusion of sero- sanguineous fluid, which varies from 200 to 500 cc. after intra- thoracic operations, and provides for detection of bleeding. A clamp is attached to a piece of Cotton tape at the head of the bed so that if any of the bottles breaks or if the suction fails in any way the chest catheter may be clamped off immediately. The bottles should be placed no less than 18 inches below the level SUPPURATIVE DISEASE OF THE LUNG AND PLEURA 1 19 FIGURE 48. Straight drainage under a fluid level. End of tube from chest is be- neath fluid level; second tube through bottle stopper is open. Bottle is placed in box on floor. of the catheter in the chest. Placing the bottles in a sturdy con- tainer, such as a wooden box, helps prevent breakage. The oscil- lation of fluid in the tube leading to the catheter is assurance that the system is functioning properly. The position of the chest catheter should be checked at regular intervals to be certain that it has not worked loose. When the system does not seem to be working properly, it should be carefully examined for loose stop- pers and kinks in the tubing, especially the tubing leading to the patient. The nurse should observe the type of drainage and call the doctor if there is excess bleeding. The bottles are arranged SO that bottle No. 1 Contains a measured amount of sterile water or normal saline, with glass tube under ſluid to which the catheter in the patient's chest is attached; it provides a reservoir for the collection of fluid. Air-tight continuity by means of con- necting links of rubber tubing between the bottles and the source of suction provides an entirely closed system of drainage with suction. The air vent provided by the long glass tube in bottle No. 2 makes it possible to control the amount of negative pres- sure exerted upon the chest. This is done by altering the length of tubing beneath the water level. If the negative pressure above the level of water in bottle No. 2 exceeds the height of the column of water in the immersed portion of the vent tube, air will be 120 NURSING IN THORACIC SURGERY sucked into the bottle through the vent tube, therefore main- taining the negative pressure at a constant level. Needless to say, the mechanism providing suction must produce a slightly greater amount of negative pressure in order to keep the system working. If bubbles are not coming through the vent tube, one may suspect that the negative pressure is less than the desired aſſlC) unt. When the drainage is to be measured, which is usually or. dered every twelve hours, the chest catheter is clamped off, the suction is turned off, the “water seal” bottle is emptied, the Con- tents measured, the bottle and tubing are resterilized, and the bottle is filled with the ordered amount of sterile solution. After reattaching it to bottle No. 2 and to the chest catheter, suction is applied and the clamp is released. In some cases, the surgeon may order simple “water Seal” drainage. The principles of care are the same as when suction drainage is used. Frequent turning and coughing are usually ordered; these may make the patient uncomfortable but are essential in pre- venting atelectasis and pneumonia. Analgesics should be given to keep him comfortable and to lessen pain while Coughing. Hold- ing a towel firmly around the chest to add support is useful while the patient is coughing. When the patient does not cough deeply, it may be necessary to stimulate the Cough reflex by suctioning through the nostril into the pharynx by means of an electric aspirator. Steam inhalations are helpful in loosening and thin- ning viscid mucus. Fluids are administered intravenously until the patient is able to take the necessary amount by mouth. Antibiotics are given intramuscularly. The patient is gotten out of bed according to his condition. It may be as soon as the third day but often he may remain in bed much longer. A high caloric, high vitamin diet is increased as tolerated and routine convalescent care is given as described previously under thoracic injuries. In the absence of complications, the chest catheter is removed in two to four days and the operative wound heals per primam. The chest is usually examined by x-ray several times during the first week. •.” The activities of such a patient are gradually increased while he is in the hospital and when he goes home he is advised to SUPPURATIVE DISEASE OF THE LUNG AND PLEURA 121 exercise according to his tolerance. The convalescent period varies with the individual. The rapidity of recovery seems to de- crease with increasing age of people; the young person frequently is very active beſore leaving the hospital. Excessive exercise such as swimming is usually ſorbidden temporarily. These patients are not handicapped in leading a normal life. A mother is able to take care of her children and carry out the household duties, and the office worker can resume his work. Only when the per- son has done work involving strenuous physical labor does it seem necessary that he be advised to change to another type of work. Complications. The mortality rate among carefully selected and prepared patients is low, far lower than the rate for the disease iſ untreated. Fatalities occur nevertheless, and are nearly always due to one or more of the three serious complications of pulmonary resection. These are hemorrhage, tension pneumo- thorax, and inſection; of the three, inſection is the most Common, the most difficult to prevent and the hardest to cure. HEMORRHAGE. The symptoms and signs of hemorrhage follow- ing lobectomy are the same as those of concealed hemorrhage elsewhere, but the diagnosis is made somewhat more easily when bright blood appears in the drainage tube. If the bleeding is rapid or persistent the surgeon must reopen the chest to control it. Large blood transſusions are often necessary. The appearance of small amounts of old blood in the drainage tube, however, may be expected as a matter of course, as there is nearly always a small amount of blood in the chest cavity at the Conclusion of the operation. INFECTION. A problem always conſronting the thoracic surgeon is the rate and completeness of healing of the bronchial stump. The healing of this structure depends somewhat upon its size, ſor small bronchial branches heal more rapidly and more readily than do the main branches or the stem bronchus. Inſection in- variably follows even the most minute leak in the bronchial closure, and, of course, air will also pass through the opening. If the leak occurs in the first seventy-two hours after operation, before the remaining lung becomes adherent to and seals over the stump, not only will inſection be spread throughout the pleural cavity but the grave Condition of tension pneumothorax will be produced. This state must be discovered at once as the application of negative pressure to the drainage tube may pre- vent mediastinal shift and asphyxiation. Prompt treatment is 122 NURSING IN THORACIC SURGERY imperative because death may occur within a few minutes after the onset of the symptoms. A leak in the bronchial stump occurring after the stump has become sealed off by surrounding lung tissue is less serious. Pneumothorax is thus prevented, and the inſection is localized. Sometimes the infection will drain spontaneously through the bronchus, with expectoration of the pus; at other times it must be drained surgically. The whole problem of treatment of these postoperative inſections of the chest is more properly discussed with the treatment of empyema thoracis. EMPYEMA THORACS Empyema thoracis is the term used to designate the occurrence of pus in the chest, and does not, in itself, indicate the amount of pus or the source of the infection. Acute empyema thoracis is the result, variously, of the introduction into the pleural space of infective material from the outside, as in a puncture wound; or of the spread to the pleural surface of an infection within the lung, as in pneumonia, tuberculosis, or pulmonary abscess; or of an inſection occurring as a Complication of an intrathoracic operation. Since this is so, it is obvious that the nature of the empyema and its treatment will depend upon the nature of the underlying cause, Chronic empyema thoracis is the usual Con- sequence of an acute case improperly treated or neglected. Postpneumonic Type. One who has seen under the microscope a slide prepared from a pneumonic lung will recall the abundant bacteria that are present in the lymphatics beneath the pleural surface of the lung. It is not surprising, therefore, that some of these bacteria gain entrance to the pleural space, and, indeed, in nearly every case of pneumococcal pneumonia, fluid containing pneumococci is present in the pleural space during the height of the disease. In the majority of instances, particularly when chemotherapy is used, the inſection is quickly overcome, the bacteria are killed, and the fluid is absorbed. In some, however, the bacteria gain the upper hand, and the inſected portion of the pleural sac then resembles an abscess. The pleural surfaces about the collection of pus become greatly inflamed, thickened, and adherent, forming a typical abscess wall. The size and location of the empyema cavities vary greatly: a massive empyema may in- volve nearly the entire pleural space, whereas a small empyema cavity may be located anywhere about the surfaces of the lung and may contain only a ſew cubic centimeters of pus. SUPPURATIVE DISEASE OF THE LUNG AND PLEURA I 23 EIGURE 49. Set-up for thoracentesis. Flask of procaine, medicine glass, small syringe and fine needles are for procaine infiltration anesthesia of chest wall. Large syringe, three-way stopcock, and large gauge long needles are for thoracentesis. Graduate is for measurement of Vol- ume of fluid aspirated, and sterile tubes are for collection of samples for culture and other studies. The character of the wall of the empyema cavity is of great importance. Early in the disease the wall is delicate and easily torn, so that improper treatment may permit spread of the dis- ease, with further collapse of the lung. Later, however, the empyema wall becomes so firm and rigid that expansion of the lung is prevented even after evacuation of the pus, and a chronic empyema is formed. It is apparent, therefore, that the optimal time for the treatment of empyema falls between these extremes. The occurrence of empyema is suspected clinically when a pa- tient recovering from pneumonia has an unexpected rise in temperature or complains of pain in the chest. Often the charac- teristic physical signs of fluid can be elicited; but when the col- lection of pus is small or deeply situated there may be no signs. Roentgen ray examination of the chest nearly always discloses the empyema, especially if a series of films has been made show- ing the progress of the pneumonia. An absolute diagnosis of empyema thoracis rests upon thoracentesis with the discovery of pus on aspiration. Decisions as to the time and form of treatment are based on the character of the pus obtained. All such speci- mens should be saved, therefore, so that comparisons may be made. 124 NURSING IN THORACIC SURGERY The widespread use of antibiotics in the treatment of pneu. monia has resulted in a much lowered incidence of postpneu- monic empyema. Trecitment of Acute Empyema Thoracis There are several methods of treating acute empyema thoracis, and it is only fair to say that most of these methods produce ex- cellent results when used by surgeons who properly understand the principles of treating empyema and the limitations of the various methods. The underlying principle for treatment, as in any abscess, is the evacuation of the pus in such a way and at such a time that the cavity will be collapsed. Technic of Open Drainage. In this method a large opening is made directly through the chest wall into the empyema cavity. After the abscess is located, an incision is made and a short seg- ment of rib removed. This procedure is readily carried out under local anesthesia, and, in the case of a very ill patient, can be done in the ward. A large soft rubber tube is inserted, and Copious dressings are applied. At first there is a rapid fall in temperature and profuse drainage. Aſter two or three days the drainage subsides, the patient's appetite improves, and he may soon get out of bed. The tube is gradually removed, and in three to four weeks the wound is healed. The most important considerations are to operate at the optimal time, and to make the opening in the proper location to provide dependent drainage. The time for operation is de- termined by the character of the pus. When the pus is the thick- ness of pea soup, it can be safely assumed that the walls of the cavity are strong enough to prevent collapse of the lung when the chest is opened. (Collapse would cause both spread of the infection and further reduction of an already impaired vital capacity.) If the pus is too thick to drain readily, the cavity may be gently irrigated once or twice daily with normal saline or Dakin's solution. The student may well ask how it is that the lung reexpands in the presence of an open pneumothorax. This mechanism has thus far defied exact solution, but it is a ſact that in properly treated patients the lung does expand and the cavity is obliterated. The best explanation offered is that the granulation tissue of the cavity walls becomes Organized into scar tissue, after which the usual contraction of scar tissue takes place, and the lung is pulled back into position against the chest wall. SUPPURATIVE DISEASE OF THE LUNG AND PLEURA 125 The advantages of open drainage are the simplicity and direct- ness of the method, the absence of complicated apparatus, and the simplicity of the after-care. The patient need not be long confined to bed or hospital. The only disadvantage, the fact that drainage cannot be safely instituted as soon as the empyema appears, is more apparent than real; for, should it prove neces- sary, large amounts of pus can be easily removed by aspiration (thoracentesis) until the time is ripe ſor operation. Open drainage may be employed even in bilateral empyema, provided care is taken to postpone operation until the walls of the cavities are sufficiently fixed. Nursing Care. For irrigation of the cavity the patient is turned slightly toward the unaffected side. After removal of the dressings a sterile curved basin is placed against the chest, under the in- cision, for the collection of the return flow of pus and fluid. The solution which was ordered is introduced into the cavity through the rubber tube by means of a sterile Asepto syringe. To ensure more Complete drainage, the patient should be turned toward the affected side before the application of dressings. Following the irrigation, the area around the tube and the incision should be cleaned by sponging. Benzalkonium chloride 1: 1000 is a satis- factory solution for this purpose. The dressing is made by placing four or five sterile fluffs around the tube and over the incision, then covering them with a large sterile cotton pad. When fre- quent change of dressings is necessary, the use of Montgomery straps' prevents the irritation of the skin and the discomfort to the patient incident to the frequent removal of adhesive. Two of these adhesive straps are fastened on either side of the dress- ing and tied over the dressing. The drainage is sometimes irritating to the skin. In such cases the area directly surrounding the wound should be protected by boric or some other mild sterile ointment. The soiled dressing should be wrapped in several thicknesses of newspaper before being burned; the basin used ſor the collection of pus should be emptied immediately, then washed and boiled. Technic of Closed Drainage. Closed drainage is carried out by introducing a small rubber tube, usually a 16 F. Catheter, through 1 Montgomery straps are made by cutting 2-inch adhesive tape in strips about 10 inches long. Three or four inches of the adhesive at each end is folded on it self. Cotton tape about 6 inches long is tied through a hole made in the double thickness of adhesive. Toothpicks, inserted in the end of the double adhesive, joined by rubber bands, may be used instead of cotton tapes. 126 NURSING IN THORACIC SURGERY Fº §: º = ºH** & º FIGURE 50. Drainage dressing held by Montgomery straps. The upper strap is fastened by cotton tapes, the lower by elastic bands over toothpicks. a trocar which has been inserted between the appropriate ribs into the most dependent portion of the empyema cavity. The operation is easily and quickly perſormed in the operating room or in the patient's bed. It must be pointed out that the procedure is a “blind” one: the operator cannot see the tissues through which he is ſorcing the trocar. The drainage of deeply situated or small collections of pus, therefore, is attended by both diſ. ficulty and danger. The catheter is, of course, closed by means of a clamp until it can be connected to the apparatus ordered by the surgeon, for the chieſ difference between the open and closed methods of drainage lies in the careful prevention of an open pneumothorax in the closed method. A number of common mishaps are encountered in using the various closed drainage systems. Sooner or later there will be leakage of pus and/or fluid about the drainage tube; this can be sometimes corrected by changing the tube to one of larger size. The drainage tube is often plugged by thick pus or lumps of fibrin, a complication requiring constant watchfulness and re- sourcefulness. The fibrin-dissolving enzymes, streptokinase and streptodornase, may be used to make the pus thin. Sometimes a clot of fibrin acts as a flapper valve over the inner opening of the catheter, so that fluid may enter but may not leave the cavity. This complication has occasionally resulted in rupture of the cavity with consequent collapse of the whole lung. Air may enter the apparatus through faulty joints, but in some instances air escapes into the cavity through the development of a bron- chial fistula. Such a fistula may result from the destructive effect FIGURE 51. Suction drainage. Note that this is a closed system. A, Source of suction; B, pressure regulator (amount of negative pressure is deter mined by distance C); D, drainage bottle; E, tubing to patient. of the infection, or from the mechanical pressure against the lung of an improperly placed drainage tube. Nursing Care. The use of all apparatus for drainage should be clearly understood by the nurse beſore she attempts to care for the patient. Care of the apparatus may be summarized in three rules: Keep the tubing clear, allow no air to enter, measure and record the drainage. In emptying the drainage bottle the nurse must be certain that the tube leading to it is clamped off tightly to prevent the entrance of air into the tube. The drainage tube is kept under fluid in the collection bottle when straight drainage is used. The exact amount of pus collected is calculated by sub- tracting from the total drainage (1) the amount of fluid placed in the bottle plus (2) the amount of irrigating fluid introduced into the cavity. The formation of a bronchial fistula presents a serious problem when closed drainage is used. Not only are the dynamics of the apparatus upset, but also there is opportunity for the irrigating fluid to run into the bronchial tree, causing continual coughing at best, or drowning at worst. When possible, open drainage is the simplest method of treating an empyema complicated by a 128 NURSING IN THORACIC SURGERY bronchial fistula. As has been seen, however, there are times when open drainage cannot be safely used. Straight or suction drainage can be used without irrigating fluids, and often prove most useful in dealing with bronchial fistulas. Care must be taken to use very mild suction, since it is not hard to suck the lung around the drainage tube in such a way as to close the tube off without draining the empyema. Trecitment of Chronic Empyema Thorcicis The modern treatment of acute empyema thoracis should seldom allow a case of chronic empyema to develop, but there are always a few hardy patients who do not seek medical aid during the acute stage. The patient with chronic empyema usually presents a small draining sinus in the chest wall overlying a cavity which is easily demonstrable in the x-ray film. Such a pa tient has, as a rule, no constitutional symptoms, and may have led a normal active life for months or years except for the annoy- ance of the purulent drainage from the sinus. The inflammatory tissue walls of the chronic empyema cavity may be a centimeter or more thick, and are as tough as Cartilage. Until recently the only method of dealing satisfactorily with this condition was to choose or devise a plastic procedure (thora- coplasty) which had for its object the obliteration of the cavity. This involves the resection of ribs, the excision of the thick scar tissue, or the implantation of pedicled flaps of muscle and skin. Experience has shown, however, that operative removal of the thickened wall of the cavity by peeling it off the underlying lung is a highly successful method of promoting healing in chronic empyema, as the freed lung quickly reexpands to fill the cavity. Bronchial fistulas often complicate chronic empyema, but will usually heal if the cavity is obliterated. Trecitment of Other Forms of Empyema Thoracis Infection of the Pleural Space Following a Penetrating Wound. This is not uncommon, and the resultant empyema may be treated satisfactorily in the same manner as postpneumonic empyema. Infrapleural Rupture of Abscess. A particularly grave form of empyema is that which results from the spontaneous rupture into the pleural cavity of a pulmonary abscess. In this instance there is a sudden overwhelming infection, usually of the entire SUPPURATIVE DISEASE OF THE LUNG AND PLEURA 129 n pleural sac, complicated by the presence of a bronchial fistula. Not only is the lung likely to be collapsed, but also a tension pneumothorax exists. To make matters worse, the type of infec- tion is usually highly virulent and mixed (composed of numer- ous varieties of bacteria). Adequate treatment, then, must in- clude immediate drainage, relief of the tension pneumothorax, prevention of an open pneumothorax, and the administration of antibiotics. The proper diagnosis is not difficult. The sudden appearance of high fever, prostration, pain in the chest, Cyanosis, and dyspnea in a patient suspected of having or known to have a lung abscess points to intrapleural rupture of the abscess. The physical signs of fluid and air in the pleural space (hydropneumothorax) are usually present, and x-ray is needed only for later confirmation. The mortality rate is high, but prompt treatment saves many lives. Closed drainage should be instituted at once. Postoperative Empyema. In postoperative empyema the treat- ment depends upon the nature of the previous operation. If all or nearly all of the lung is still present, the treatment does not differ from that which is used in postpneumonic empyema, except that a bronchial fistula will nearly always be present. Infection fol- lowing the removal of the whole lung is extremely troublesome to treat, since the entire pleural cavity is infected and there is no simple method of collapsing or filling that space. In the event that open drainage, irrigation, and antibiotic therapy are un- availing, a plastic procedure to collapse the cavity is necessary. SUMMARY Lung abscess, bronchiectasis, and empyema thoracis are the common suppurative infections of the lung and pleurae. Suc- cessful treatment requires a combination of general medical care, antibiotics, and surgery. In the nursing care of these pa- tients skills in the technics of postural drainage, “water seal” suc- tion drainage, and in the care of oxygen therapy equipment are necessary. VOCABULARY REVIEW bronchoscopy Montgomery thoracoplasty bronchiectasis straps pneumonectomy lobectomy bronchopleural empyema fistula 130 NURSING IN THORACIC SURGERY SUGGESTED READING 1. Bickford, Ellinor, and Budd, Esther: Pulmonary Resection. Am. J. Nursing, 52:40–41 (January) 1952. . Bugden, Walter F.: Pulmonary Resection. Am. J. Nursing, 52:38-39 (January) 1952. 3. Carr, Duane, and Robbins, S. Gwin: Streptokinase and Antibiotics in the Treatment of Clotted Hemothorax. Ann. Surgery, 133:853–866 (June) 1951. 4. Pulaski, Edwin J., and White, Thomas T.: Streptomycin in Surgical Infec tions; Lung Abscess and Empyema. Ann. Surg., 128:312–318 (August) 1918. . Touroſf, A. S. W., Nabatoſſ, R. A., and Neuhof, H.: Acute Putrid Abscess of Lung. J. Thoracic Surgery, 20:266–271 (August) 1950. 2 5 CHAPTER 13 Surgery of Pulmonary Tuberculosis Of the various ſorms of human inſection with the tubercle bacil- lus, pulmonary tuberculosis is the most common, and is one of the major causes of death. The student nurse, during the course of her study of medical diseases, has already become familiar with the clinical picture, the diagnosis, and the general medical care of the patient who has pulmonary tuberculosis." She is also well aware of the importance of early case-finding on a Community- wide basis, and of the need for isolation of the inſectious patient. The treatment of pulmonary tuberculosis is primarily medical; new and promising chemotherapeutic and antibiotic agents are under extensive trial. There are, however, indications for Sur- gical therapy in this disease. COLLAPSE THERAPY In pulmonary tuberculosis the lung is the site of the inſection; it is thereſore to the lung that specific measures to produce physiologic rest are directed. The first of these is to teach the patient to control and minimize coughing. With practice and perseverance this ordinarily violent movement of the diaphragm and other muscles of respiration can be reduced to one that is barely perceptible. 1 See Brown, pages 985–1026. SURGERY OF PULMONARY TUBERCULOSIS 131 The regular activity of the lung is breathing; since one must breathe to live, it would seem impossible at first glance to put the lung at rest. Experience has shown, however, that if the patient restricts his physical activity and thus reduces to a minimum the oxygen need of his body, a small amount of healthy lung is suſ- ficient to oxygenate the blood. The student can get a rough idea of the minimum amount of lung needed by contrasting the vol- ume of air ordinarily inspired by a person at rest (300 to 400 cc. per breath) and the vital capacity (2 to 3 liters normal average). Furthermore, the lung, in Common with most of the organs and tissues of the body, possesses the ability to increase its capacity for work: one lobe may, in time, be able to accomplish nearly as much oxygenation of the blood as was originally accomplished by the whole lung. In order to rest an affected hand, a patient may wear his arm in a sling; he may reſrain from speaking to rest the vocal cords; but no one can voluntarily restrict the activity of one lung. This must be done by means of artificial collapse of a part or all of the lung, and it is the accomplishment of this collapse that is the principal aim of nearly all the surgical procedures undertaken for the cure of pulmonary tuberculosis. The ideal type for collapse therapy is the patient who has an early inſection limited to one lung, and in such a case the prog- nosis is good. Even in patients with advanced tuberculosis of one lung much can be accomplished. The collapse of a tuberculous cavity in the lung may convert an “open” lesion into a “closed” one; the patient thus ceases to expectorate large quantities of virulent tubercle bacilli and is no longer highly infective both to himself and to others. In mild cases of bilateral disease a partial bilateral collapse is oſten successful, but in advanced tuberculosis of the lungs the outlook is grave and collapse therapy is usually not feasible. The general condition of the patient is a matter for careful study; tuberculous patients, as a rule, are sicker than they appear, and withstand poorly any surgical procedure or postoperative complication. The use of the roentgen ray in diagnosing and following the clinical course of the tuberculous patient is probably the most important modern contribution to the subject. By means of repeated fluoroscopic examinations and regular x-ray film studies, it is possible to make early diagnoses and to follow in exact detail the results of collapse therapy. 132 NURSING IN THORACIC SURGERY : : k -3. … ** $* * º t * #| .# º || | |: ; * || : FIGURE 52. Set-up for administering artificial pneumothorax. Technics of Pulmondry Collapse The methods for obtaining pulmonary collapse are: (1) pneu- mothorax; (2) oleothorax; (3) phrenic nerve block; (4) pneu- monolysis; and (5) thoracoplasty. Pneumothorax. The simplest and most effective means of col- lapsing part or all of a lung is the induction of artificial pneumo- thorax. Aſter infiltration of the chest wall with procaine, a needle is carefully introduced into the pleural space and a measured amount of air is slowly injected. The lung is thus pushed away from the inner chest wall. Certain precautions are necessary. Strict asepsis must be observed, although the air that is used is ordinarily not sterilized, there being too few pathogenic organ- isms in a small amount of clean air to cause an inſection. A pres- sure of only a few millimeters of water should be used to inject the air, for a high pressure may tear adhesions or the lung itself, causing hemorrhage or infection, or both. The amount of air used on the first occasion should be limited to 300 to 500 cc., since SURGERY OF PULIMONARY TUBERCULOSIS 133 the patient must be permitted to adjust himself gradually to the reduction in his vital capacity. The amount of pulmonary Col- lapse is visualized under the fluoroscope or on x-ray films, and at further sittings additional amounts of air are introduced until the desired amount of collapse is obtained. The air thus injected is slowly absorbed by the pleura, and it is necessary, therefore, to add more air from time to time, usually at intervals of six weeks to three months. The advantages of this method for obtaining collapse are its simplicity and ease; the collapse need not be permanent (when the lesion is healed the affected lung may be allowed to expand and resume its normal function); and in favorable cases a more complete collapse of the lung can be secured than by any other method. On the other hand, the impermanence of the method is at times a disadvantage: there is necessity for refills, and the col- lapse is not constantly maintained. Furthermore, the presence of pleural adhesions may make the collapse incomplete or impos- sible. There is also the not too remote possibility that a massive empyema will result from the introduction of pathogenic bacteria or from the tearing of a delicate adhesion between the pleura and the lung. By and large, however, artificial pneumothorax is safe and successful; it is used widely and, in fact, so Commonly that it is scarcely regarded as a surgical procedure. Pneumoperitoneum. Another method used to obtain Collapse of the pulmonary tissue is pneumoperitoneum. Large amounts of air are introduced by needle into the peritoneal cavity. This air naturally rises into the subphrenic spaces iſ the patient is upright, and will push the diaphragm upward into the thorax. As in pneumothorax, the air is gradually absorbed and refills are necessary. Oleothorax. The necessity ſor refills inherent in a program of treatment by means of artificial pneumothorax led to the trial of substances other than air ſor compression of the lung. The ideal material would be nonabsorbable, fluid, and light in weight. In Some clinics a light paraffin base oil is used. Following the success- ful induction of Collapse by means of artificial pneumothorax, an equal amount of oil is substituted for the intrapleural air. Re- fills are unnecessary. Even the most inert substances are somewhat irritating to the pleura, however, and adhesions form which render reexpansion of the lung impossible, should it be later de- sired; there is also the difficulty of completely removing the oil. 134 NURSING IN THORACIC SURGERY An additional real danger lies in the presence of so much ſoreign material if empyema should occur. This method is not widely used at present. Phrenic Nerve Block. The paired phrenic nerves serve as path- ways for the impulses which control the activity of the powerful diaphragmatic muscles. Arising from the fourth and fifth cervical nerves, the phrenics are deeply situated in the neck, pass into the mediastinum along with the great blood vessels, and then course down to the diaphragm on either side. Division of one of the phrenic nerves results in flaccid paralysis of the diaphragm on the same side. The paralyzed diaphragm balloons upward, and the volume of the pleural cavity on that side is thus much reduced. This makes available an additional means of furthering the Col lapse of a lung. Paralysis of the diaphragm is second only to pneumothorax in value, and is used to secure collapse in patients who have had unsuccessful or only partly successful pneumothoraces. Some au thorities, indeed, are of the opinion that phrenic nerve block should be used in conjunction with nearly all pneumothoraces as well as in the unsuccessful ones. Fortunately for the surgeon there is one portion of the phrenic nerve which is readily accessible. Aſter procaine infiltration of the skin at the base of the neck, a small incision is made just above and parallel to the inner portion of the clavicle. The phrenic nerve is here easily exposed and identified. In the case of patients who have a good prognosis, with expectation of using the lung after the lesions are healed, the procedure of choice is to crush the nerve thoroughly without dividing it. Immediate paral ysis of the diaphragm results, but it is not permanent since the nerve will regenerate in six to nine months. In the case of those needing permanent collapse, however, the nerve is divided (phrenicectomy) and a segment of it removed so that regenera- tion is effectively prevented. In competent hands the operation is without risk, and can be performed almost without regard to the general condition of the patient. After phrenic nerve block, the patient is kept flat in bed with no exercise ſor twenty-ſour hours; he is not even permitted to feed himself. By thus reducing the patient's activity, respiratory activity is held to a minimum, affording optimal conditions for elevation and fixation of the paralyzed diaphragm. Pneumonolysis. In some patients the accomplishment of a satisfactory collapse is prevented by adhesions between the lung SURGERY OF PULIMONARY TUBERCULOSIS 135 FIGURE 53. Phrenic nerve block. and the inner chest wall. When such adhesions are few in num- ber, the surgeon may undertake their division (pneumonolysis) so that a better collapse can be obtained. In performing an open intrapleural pneumonolysis the chest is opened and the adhesions are divided under direct vision; this method has the advantages afforded by good exposure so that bleeding and injury to the lung may be avoided, but has the disadvantage of being a rather Severe procedure to carry out on ill patients. Closed intrapleural pneumonolysis is performed by inserting into the pleural space a cystoscope-like instrument equipped with cautery and light; ad- hesions are divided by means of the cautery. This operation is readily accomplished under local anesthesia, even in very ill pa- tients, but has certain inherent disadvantages: not all adhesions are accessible, and there may be great difficulty in controlling bleeding. A risk attendant upon both methods is that of inſec- tion, for often the lung is drawn up into the adhesive band so that bacteria may be spilled into the pleural sac upon division of 136 NURSING IN THORACIC SURGERY the band. Both of these procedures are undertaken as adjuncts to artificial pneumothorax, and it is necessary to maintain the additional collapse resulting from the operation by the introduc tion of additional amounts of air. Extrapleural Pneumonolysis. When many and dense adhesions prevent intrapleural pneumonolysis, the procedure of extra- pleural pneumonolysis is sometimes undertaken. In this opera tion an attempt is made to strip the parietal pleura from the inner surface of the intercostal muscles and ribs, thus forming an extrapleural space into which air may be introduced to maintain collapse. As a rule, this radical procedure is poorly tolerated by ill patients, and is therefore seldom used. Extrapleural Thoracoplasty. As a final method of obtaining col lapse of the lung the surgeon can carry out plastic procedures upon the chest wall (thoracoplasty) which actually reduce the capacity of the chest. A number of different methods have been evolved, but the essential feature of all of these is the removal of some part of the bony thoracic cage, permitting the soft parts of the chest wall to fall in upon the lung. Thoracoplasty is a major surgical procedure, and an irrevoca ble one; therefore the greatest care must be used in selecting the proper patients and in choosing the proper time for operation, Patients with progressive unilateral tuberculosis, in whom all other forms of collapse therapy have been unsuccessful or are impossible, are suitable for thoracoplasty. An advantage of the procedure is that it may be divided into multiple stages, so that no more need be attempted at one time than the patient can tolerate. By careful preparation the patient is gotten into as good gen- eral condition as possible. Phrenic nerve block should, of course, be carried out before thoracoplasty, in order to secure the maxi- mum degree of collapse. Selection of the time for operation is based upon such considerations as the patient's temperature, pulse rate, weight, hemoglobin, and mental attitude. Prepara- tions should be made for blood transfusion. General or local anesthesia may be used. The incision is usually made between the inner border of the scapula and the spine, and is carried down around the lower angle of the scapula. The heavy muscles are divided, and the scapula is then easily retracted laterally, giving good exposure of the posterior portions of all the ribs. Beginning at the upper end, segments of the ribs are removed, the utmost care being taken not to enter the pleural space, or to traumatize the lung in any way. The attempt is made to remove as much of SURGERY OF PULMONARY TUBERCULOSIS 137 %X& §º W. Mºº º - 2 1:32 FIGURE 54. Position of patient on operating table and location of incision for left thoracoplasty. Insert shows final result of right thoracoplasty; despite cxtensive removal of ribs there is little outward evidence of deformity. each rib as possible, ſrom the vertebral attachments posteriorly to the Costal cartilages anteriorly. In very ill patients the opera- tion is terminated aſter the removal of two ribs, but stronger patients may tolerate the removal of three or four. The scapula is replaced, the muscles and skin are sutured, and a snug dress- ing is applied to compress the chest wall as much as possible. The patient's condition is estimated by his pulse rate, blood pressure, and Color; significant change in any of these is a warning to stop the operation at once. The comfort of the patient and the degree of collapse after operation are increased by the use of Sandbags or a bag containing buckshot. Some surgeons prefer to have the patient lie with the operative side down, upon correctly Placed sandbags, while other surgeons prefer to have the opera- tive side uppermost, weighted down by a saddle-shaped bag of shot. Intervals of two to three weeks between stages are the most Satisfactory, since a shorter time does not permit full recovery of the patient, and a longer interval tends to lessen the degree of ultimate collapse because there is some regeneration of the ribs from the periosteum which is not removed. Strong patients in good condition will tolerate a two-stage thoracoplasty, but very 138 NURSING IN THORACIC SURGERY ill patients will require three or more stages. The same incision is used for the later stages. The final result is a permanent one, and the degree of collapse is considerable, although not quite so complete as with the most successful pneumothoraces. There is great deſormity of the chest, but this is not too obvi. ous when the patient is clothed. When the patient has regained sufficient strength, the outward appearance of this deformity can be largely overcome by the use of exercises designed to strengthen the muscles of the back, thus preventing undue curvature of the spine and lowering of the shoulder on the operative side. Complications. Despite every precaution, serious complications often ſollow thoracoplasty. Surgical shock may occur, and is best treated by prevention, that is, by stopping the operation beſore the patient becomes shocked. Postoperative hemorrhage is un Common. Cyanosis due to the sudden reduction in vital capacity is of ſrequent occurrence, and is treated by the use of the oxygen tent or mask. Fat embolism occurs occasionally as the result of the multiple rib resections. Spread of the tuberculosis may take place iſ the lung has been traumatized. Infection of the wound and empyema are also serious though infrequent sequelae of the Operation. Combined Thoracoplasty and Segmental Resection. In recent years more radical operative procedures have been carried out in selected patients. Since the upper portion of the upper lobe of the lung is most often involved, it has seemed beneficial to remove the diseased portion of the lung in combination with extra- pleural thoracoplasty. This has the great advantage of eradicat- ing the focus of inſection and thus eliminating the possibility of spread of the disease. Nursing Care of Patient with Thoracoplasty. The patient ad. mitted to the surgical unit usually comes ſrom a tuberculosis sana- torium where he has had excellent teaching in proper self-care. He is well aware that the uncovered Cough, the contact of his hand with his mouth and the contamination of other areas by his hands are the greatest hazards in the spread of the bacilli. He has learned the importance of procedures necessary to protect others from inſection. His spirits are usually low. He knows that thora- coplasty is his last chance for collapse therapy and cure. He heard much in the Sanatorium about deformity ſollowing thoracoplasty and must be reassured early about methods for overcoming this. Isolating him in a room from surgical patients with other con- ditions is essential. In caring for him all personnel must Con- SURGERY OF PULMONARY TUBERCULOSIS 139 scientiously carry out respiratory isolation technic to protect themselves and the other patients against inſection. Aſter being accustomed to the association with many other patients at the sanatorium, this complete isolation brings on loneliness unless there is adequate diversional therapy. Providing the patient with a radio, reading material and an appropriate form of occupational therapy for use before operation and during the periods of convalescence will help him to pass the time. Preoperatively the care depends on the various examinations, supportive therapy and instruction which the surgeon orders ac- cording to the individual patient. Usually it includes x-rays, the collection of sputum specimens, vital capacity tests and bron- choscopy. Antibiotics and a high vitamin, high caloric diet with adequate fluid intake are essential. Frequently the patient is taught abdominal breathing by the physical therapist. The force of the abdominal muscles against the viscera pushes up the dia- phragm to allow for exchange of air from the lower lobes of the lungs. At least three days beſore operation, teaching the patient the essentials of good posture while sitting up and lying in bed is begun by the physical therapist and/or nurse. There is need for the patient to understand the criteria of good posture so that the direction of activity between stages and aſter operation is met with cooperation in order to keep the disfigurement at a mini- Illul Il. The immediate preoperative care for all stages is similar to other types of chest surgery. In addition to the usual postopera- tive unit, Oxygen equipment is necessary and it is advisable that an aspirator be close at hand. Following operation, the patient is placed in the lateral posi- tion. If the patient's blood pressure is low, the foot of the bed should be raised. He should be turned every hour ſor the first twelve hours and every two hours thereaſter. Some surgeons order the patient to be turned only on the side of operation and the back, while others permit him to turn on either side. The rate and quality of the pulse, the blood pressure, the color of the patient and the dressings should be observed as for any patient With chest surgery; unfavorable signs and symptoms should be immediately reported to the surgeon. The chest should be ex- posed ſrequently the first day to observe the respirations of the patient to insure that exchange of air is normal. Paradoxical respirations, in which the weakened chest wall is sucked in during inspiration, may occur and must be reported immediately. The patient must be made to Cough each hour. The nurse 140 NURSING IN THORACIC SURGERY should give analgesics and splint the wound with the palm of her hand to help prevent pain while coughing. When Coughing is not forceful enough, pharyngeal suctioning with an aspirator will stimulate coughing and also remove excess mucus. Intravenous ſluids are administered at intervals until there is adequate intake by mouth; antibiotics are given as ordered. The diet is increased according to the tolerance of the patient. Oxygen therapy is usually discontinued aſter twenty-four hours or when breathing is easy without an increase in rate of respiration or dyspnea. It has been ſound that giving the patient special attention such as turning him, rubbing his back and reassuring him at regular intervals will lessen the demand for medications to re- lieve pain. To withhold medications when necessary should be guarded against, but good nursing care directed toward making the patient feel that those caring for him are interested, without any demands from him, tends to lessen tension, gives him peace of mind and seems to lessen pain. Usually, on the third day following each stage of the thoraco. plasty the nurse or physical therapist assists the patient in exer. cising the arm on the operative side. The exercises are limited to the tolerance of the patient and must not be carried out when there are signs of dyspnea. He should be encouraged to move freely in bed and to move his arm in all directions, increasing his activities according to his tolerance. At first weariness takes place with only a small amount of motion; encouragement and reassurance are necessary. As his condition improves, appealing to his sense of pride and emphasizing that people with good pos. ture Command respect and admiration from others are worth While in raising his morale. Placing a large mirror on the wall, where he may observe himself while sitting up in bed, not only makes him more conscious of his position but also enables him to practice posture toward better alignment. He is usually permitted out of bed for short periods of time between operations. This not only helps raise his morale but also tends to improve muscle strength. He is usually transferred to the sanatorium about ten days after the last operation. Each patient's activity is increased ac- Cording to his condition, but, by and large, he is quite inactive and recuperates as a bed patient for the first three months after his return to the sanatorium. After this, he is permitted out of bed. Gradually his activities are increased and bed rest is de. creased so that after another two to six months he is permitted SURGERY OF PULMONARY TUBERCULOSIS | 4 | to return home. During his whole convalescence he is encouraged to maintain good posture. None of these patients are permitted to return to work until one year after the operation. The work that they may do is often restricted to that which is sedentary or that which requires a minimum amount of exertion. However, many patients have been able to increase their activities remarkably. Frequent check-ups by the doctor are emphasized so that close follow-up care may be given. These people can lead useful and reasonably normal lives. TUBERCULOUS EMPYEMA Tubercle bacilli may gain access to the pleural space either by direct spread from the lung, or as the result of tearing the tuberculous lung during the perſormance of any of the surgical procedures that are undertaken to produce collapse. The em- pyema caused by the tubercle bacilli is apt to be low grade rather than fulminating, but it is progressive and very resistant to treat- ment. The walls of the empyema cavity are made up of typical tuberculous granulation tissue, and become enormously thick- ened and scarred, contributing to the difficulty of the cure. The various forms of surgical drainage do not constitute adequate treatment for tuberculous empyema and, indeed, are likely to be harmful, for secondary bacterial invaders may enter the drained cavity and cause a mixed infection. Tuberculous empyema should be suspected when the symp- toms and signs of fluid in the pleural space appear in patients who are known to have active pulmonary tuberculosis. Exam- ination of the fluid serves to differentiate empyema from a simple pleural effusion, a condition that often accompanies early tu- berculous activity but tends to disappear with the onset of healing. The most successful treatment consists in collapsing the empyema cavity by thoracoplasty, care being taken not to enter the empyema cavity during the procedure. If the cavity is broken into, tuberculous infection of the wound results and may be extremely troublesome to clear up. In favorable cases the empyema will heal, but the percentage of cures is far lower than in the other forms of empyema. The rupture into the pleural space of a tuberculous cavity causes a fulminating, highly fatal form of empyema, similar in most respects to that which follows the spontaneous intrapleural rupture of a pulmonary abscess. In this, instance the tuberculous infection is complicated by a secondary mixed infection of great 142 NURSING IN THORACIC SURGERY virulence, and at times by a bronchial fistula. In these cases im- mediate surgical drainage is necessary to save the patient's life even though the course of the tuberculous infection is little in- ſluenced. This can be dealt with later if the patient survives the initial mixed inſection. TUBERCULOSIS OF THE RIBS AND STERNUM These lesions are nearly always secondary to pulmonary tuber- culosis, and oſten are caused by direct extension of the disease [rom the lung to the bones and cartilages of the thoracic cage. There is first a little swelling of the affected part, but no pain or redness. Gradually the typical “cold abscess” of tuberculosis de- velops; fluctuation appears but still there is no pain. Aspiration of the lesion yields thick Creamy pus from which the tubercle bacilli can be recovered. Finally, if the lesion progresses, the overlying skin becomes red, shiny, and thin; ultimately rupture occurs, and pus is discharged. Unlike other abscesses, this lesion does not heal following drainage or rupture: a draining sinus TCIIlal IOS. As in all forms of tuberculosis, healing depends upon the patient's resistance. In favorable cases the lesion may regress, finally healing with only a scar leſt to mark the site. In addition to general measures directed toward the improvement of the patient's condition, healing may be expedited by the surgical excision of the infected portion of bone or cartilage where this is feasible. SUMMARY Nursing the patient who is having surgery for pulmonary tu. berculosis constitutes a great challenge, for these patients are long-term problems, are critically ill, and require much reas- surance, and instruction as well as regular nursing care. The need for careful isolation technic is emphasized. Collapse of the dis- eased lung tissue is the goal; removal of the diseased segment combined with collapse of the space previously occupied by this segment is receiving extensive trial. Antibiotic agents have im: proved the outlook greatly. VOCABULARY REVIEW Sanatorium e extrapleural dyspnea pneumonolysis paradoxical thoracoplasty artificial respiration pneumothorax NEOPLASTIC DISEASE OF THE RESPIRATORY ORGANS 143 SUGGESTED READING . About the New Anti-tuberculosis Drugs. Am. J. Nursing, 52:574 (May) 1952. 2. Ellison, Bess M.: Nursing Care in Collapse Therapy. Am. J. Nursing, 50: 473–475 (August) 1950. 3. Getz, H.; Nutrition and Tuberculosis. Nutrition Review, 5.97 (April) 1947. 4. Kezar, Vera: Tuberculosis with Pneumonectomy. Am. J. Nursing, 49:188- 199 (March) 1949. 5. Riley, Arnold O., and Longhurst, Grace M.: Pulmonary Decortication. Am. J. Nursing, 52:878-880 (July) 1952. 6. South, Jean, and Jones, Frank T.: Tuberculosis Control in the General Hos- pital. Am. J. Nursing, 52:1094–1095 (Sept.) 1952. 7. Tetbrock, Harry E., Fisher, Martin M., and Mamlok, Eric R.: The New Drug —Isoniazid. Am. J. Nursing, 52:1342–1344 (Nov.) 1952. I CHAPTER 14 Neoplastic Disease of the Respiratory Organs The entire respiratory tract is lined by epithelial cells which are subjected to nearly as much wear and tear as are the epithelial cells of the skin. It is not surprising to find, then, that epithelial tumors of the respiratory tract are common. There are several different types of epithelial cells among the myriads which form the lining of the respiratory tract and, therefore, there are several kinds of epithelial tumors, some of them benign and others malignant. The lungs, pleura, and mediastinum are also extremely Com- mon sites for metastases from tumors located elsewhere, because of the constant return of blood and lymph from the other organs and the extremities. PRIMARY NEOPLASMS OF THE BRONCH AND LUNGS Tumors of the lung occur in patients of all ages, but are more common after the fourth decade of life. The usual first complaint is a persistent nonproductive cough. Expectoration of blood (hemoptysis) is another frequent symptom. The quantity is ordinarily small, and great care must be taken to discover the origin of the blood, since slight bleeding from the nasopharynx or gums is Common. A sensation of Constriction or oppression in 144 NURSING IN THORACIC SURGERY the chest may occur; at times there is actual pain. Later, if the tumor is malignant, loss of weight and weakness (cachexia) are noted. An early, small neoplasm is not readily detected by phys: ical diagnosis or roentgenography. As the tumor becomes larger, or when the changes incident to obstruction of a bronchus occur, physical signs and x-ray evidence appear. Another common oc- currence is the formation of fluid in the pleural sac (hydro- thorax or pleural effusion); such fluid often contains blood and, at times, recognizable tumor cells. Since the onset of pulmonary tumors is usually insidious, many patients have no complaints until the tumor has been present for a considerable time. In many cases it is also most difficult to find out whether the patient has a tumor or tuberculosis, a matter of great importance since the treatment of the two conditions is so different. Careful examination of the sputum is necessary. Bronchoscopy is a routine procedure, and will reveal tumors situ- ated in, or adjacent to, the trachea and the main bronchi. When the growth can be seen, a small portion is removed for study (biopsy). When no tumor is visible, further inſormation can be obtained from roentgen films made after the introduction of Lipiodol into the bronchial tree. Irregularities in the bronchial outlines and obstructions of the bronchi or bronchioles are thus visualized. Benign Tumors. A common tumor arising from the lining of the trachea or the bronchi is the benign epithelial papilloma. A tiny tumor of this sort growing in the trachea or stem bronchus may cause a most distressing cough; ſortunately most of these small papillomata can be destroyed successfully by fulguration (electric cauterization) through a bronchoscope. Biopsy and an exact diagnosis must be made beſore treatment, because malig. nant tumors do not respond favorably to such therapy. When situated in a smaller bronchus, the papilloma cannot be seen, and is likely to be untreated until it is large enough to obstruct the small bronchus, so that the first symptoms and signs are those incident to the resultant bronchiectasis. The proper treatment under these circumstances is the removal of the in- volved segment of the lung. Cancer of the Lung. Prior to 1933 cancer of the lung was a uni- formly fatal disease; in that year Graham successfully removed a Cancerous lung and thereby cured the patient. Since then much knowledge has been gained in regard to the technic of complete removal of a lung (total pneumonectomy). Primary carcinoma of NEOPLASTIC DISEASE OF THE RESPIRATORY ORGANS 145 the lung is nearly as common a disease as carcinoma of the stom- ach, and is similarly difficult to cure because the tumor grows in- sidiously and without symptoms: diagnosis is seldom made before the growth has extended beyond the confines of the organ from which it has arisen. These tumors do not respond well to radia- tion therapy, and until some better means is discovered, the patient's best chance lies in the early diagnosis of the disease fol- lowed by prompt removal of the affected lung. It is, of course, true that if the tumor involves the trachea or the mediastinum, Or has invaded the pleura or the chest wall, or if there are metastases elsewhere, removal of the lung will not be curative. Total Preumonectomy The removal of an entire lung is indeed a formidable pro- cedure, but when carried out properly the mortality rate is low and the discomfort and disability surprisingly little. As a result of this operation, all of the exchange of gases between the air and the circulating blood must be carried out in the remaining lung. Anesthesia. During the operation, the anesthesiologist must be able to control respiration at all times; this necessitates the use of an intratracheal tube and the use of positive pressure while the chest is open. Since there is ventilation of but one lung, the anesthetic agents used must necessarily permit the use of a high concentration of oxygen. Operation. Most surgeons prefer the posterior approach. The pulmonary artery and the pulmonary veins are carefully iso- lated, ligated and divided. The main bronchus is also divided, and the stump tightly closed by suturing. The whole lung is then removed from the pleural cavity, together with adjacent medias- tinal lymph nodes. The chest wall is closed tightly without drain- age. The student may well ask what occupies the space in the chest formerly filled by the lung. A large part of that space is oblit- erated by a gradual shifting of the mediastinal structures toward the operative side, and by the elevated position of the paralyzed diaphragm. The cavity remaining, however, is still large, and eventually comes to be filled by a curious tissue, like Swiss cheese, probably the end result of the coagulation and organiza- tion of tissue fluid that gradually accumulates there. Iſ, on the other hand, the cavity becomes infected, as may happen when the bronchial stump leaks, healing does not follow simple drainage 146 NURSING IN THORACIC SURGERY of the infection: it is necessary to Collapse the cavity by means of some type of thoracoplasty. Complications. This undeniably hazardous operation is likely to cause some degree of surgical shock, and intravenous fluid, preſerably whole blood, should be administered during the pro- cedure. Just as aſter lobectomy, the most serious complications are hemorrhage and leaking of the stump of the bronchus; fol- lowing pneumonectomy, however, either hemorrhage or infec- tion, or a combination of these is much more dangerous, since the vessels involved are very large ones, and since an infectious process will spread through the entire pleural space. The possible development of a tension pneumothorax must be constantly borne in mind. Nursing Care. The patient who has cancer of the lung is usu- ally an older person than one who has a resection for bron- chiectasis. The general principles of care are the same but, be- cause of the difference in age and a greater physiologic distur- bance caused by pneumonectomy, certain aspects of care should be emphasized. For the first ſew days, the patient is encouraged to lie only on the operated side and the back to prevent the accumulating fluid in the pleural cavity of the operated side from forcing the medi- astinum towards the unoperated side. The use of oxygen therapy is required for a longer period of time but rarely more than four days. It is judicious to leave the equipment at the bedside ſor a twenty-four hour period after it is discontinued while the patient is given a trial without oxygen. The nurse must be especially careful in the administration of parenteral fluids, because of the danger of overloading the circulation, with resultant pulmonary edema. The rate of flow of the ſluid should not exceed 50 drops per minute unless spe- cifically ordered. The older the patient, the more necessary is this precaution. Symptoms of this complication are dyspnea, frothy sputum and rales in the chest. The patient should be en- couraged to take an adequate amount of ſluid by mouth as soon as he has recovered from anesthesia; this will obviate the need for parenteral ſluid and thus will minimize the danger of embar- rassing the circulation. & Occasionally the surgeon drains the Cavity through a catheter into a Water Seal bottle, but usually the fluid is not removed. Changes in respirations should be noted and dyspnea or cya- nosis should be reported immediately. | NEOPLASTIC DISEASE OF THE RESPIRATORY ORGANS 147 The advantages of early ambulation are obvious but an older person who has had his entire lung removed should not be forced out of bed too soon. The surgeon will allow the patient to be up according to the individual case. Prevention of atelectasis in the remaining lung is aided by encouraging the patient to cough and breathe deeply to force out the accumulated secretions. Intratracheal aspiration may be necessary. A high caloric, high vitamin, high protein diet should be given. Encouraging the patient to eat is essential so that weight loss and strength may be regained. During the convalescent period in the hospital, which is usu- ally not less than two weeks, the patient should be taught the es- sentials of good posture. Abdominal breathing exercises have been helpful by lowering the diaphragm and thus increasing the vital capacity. Before the patient leaves the hospital, a return appointment to the surgeon should be made. Follow-up care is essential and the patient should have an explanation concerning this. Guidance for activities during the period of convalescence should be outlined for the patient. Gradually, exercise may be increased but only according to tolerance. The patient finds that dyspnea comes on very quickly at first, but that this decreases greatly aſter several months of convalescence. Many patients are able to resume work, when not physically strenuous, and enjoy an active life. NEOPLASMS OF THE MEDIASTINUM AND CHEST WALL The mediastinum contains such important structures as the heart, the great vessels, the trachea, the esophagus, the thymus, and many lymph nodes. If one excepts tumors of the trachea and esophagus, it is a fact that the great majority of the remainder of mediastinal tumors are the result of secondary (metastatic) in- vasion of lymph nodes by malignant tumors arising elsewhere in the body. For such a condition, obviously, surgery affords no hope of cure. Benign tumors of the mediastinum do occur, how- ever, and are usually dermoid cysts, arising probably as the result of some mischance during fetal development. Tumors of the mediastinum do not, as a rule, produce any symptoms until they reach sufficient size to encroach upon the adjacent structures, and these symptoms vary depending upon which structures are involved. The first complaint may be a 148 NURSING IN THORACIC SURGERY cough, from pressure on the trachea, or there may be difficulty in swallowing due to pressure upon the esophagus. A feeling of substernal weight or oppression is not uncommon. Examina- tion usually shows enlargement of some portion of the medi- astinum, which is confirmed by the x-ray film. The surgical removal of benign tumors of the mediastinum is accomplished with but little risk, and cure is permanent. The same operative approach is used as for pneumonectomy. Since the chest wall is composed of skin, muscles, bone, car tilage, nerves, and blood vessels, it is not surprising that there is a considerable variety of neoplasms. In general, these tumors are the same as those arising from similar tissues elsewhere in the body, and must be diagnosed and treated in the same way. In the past, the surgeon was somewhat limited in the removal of malig- nant neoplasms of the chest wall by the fact that extensive de- fects in the chest wall were not compatible with life since the mechanics of intrathoracic pressure were altered. It is now pos- sible to remove a large portion of the chest wall, replacing the ribs and muscle with tantalum mesh. This nonreactive metal prosthesis serves to stabilize the thoracic wall, permitting normal respiration. SUMMARY Pain in the chest, persistent cough, and bloody sputum may be Symptoms of cancer of the lung. If discovered early, cure is at- tainable by removal of the lung, an operation which is attended by surprisingly little disability aſterward. VOCABULARY REVIEW hemoptysis pneumonectomy tantalum mesh papilloma dermoid cyst pulmonary edema SUGGESTED READING : A Cancer Source Book for Nurses. American Cancer Society, Inc., New York. 1950, pp. 82–84. 2. Cancer Nursing. N 1950, pp. 56, 74. . Graham, Evarts A.: Considerations of Bronchiogenic Carcinoma. Ann. Surg. 132:176-187 (August) 1950. Overholt, R. H., and Schmidt, I. C.: Silent Phase of Cancer of the Lung. J.A.M.A., 141:817–820 (November 19) 1949. . Sweet, Richard H.: Thoracic Surgery. Philadelphia, W. B. Saunders Co., 1951, pp. 171–179. ational Cancer Institute and N. Y. State Dept. of Health. 5 Unit III. NURSING IN VASCULAR SURGERY CHAPTER 15 Circulatory Disturbances: Thrombosis; Embolism; Gangrene Physiology of Circulation. The circulating blood brings the necessities of life to the cells of the body, and takes from them the products of metabolism. To maintain the circulation is the task of the vascular system. The powerful rhythmic contractions of the heart pump the blood into the aorta and the large arteries which arise from it; the elasticity of the thick muscular walls of these vessels helps to force the pulsating stream of blood into the smaller arteries and arterioles. The blood finally reaches the nu- merous tiny capillaries. These have thin walls, and are so ar- ranged that the blood which courses through them moves at a relatively slow rate, which allows time for the exchange of chemicals between the blood and the tissues. The blood in the capillaries drains into venules, which are tributaries of the larger veins that accompany the main arteries; 149 150 NURSING IN VASCULAR SURGERY finally the blood reaches the great veins which empty into the heart. Veins have thin walls in contrast to arteries, and the blood is impelled through the veins not so much by the pumping action of the heart as by a combination of other means. The force im- parted to the stream of arterial blood by the heart gradually diminishes until there is only a slight impulse left when the blood passes out of the capillaries into the venules; Consequently, venous pressure is much lower than arterial pressure. But blood must be returned to the heart as rapidly as it is pumped out, since, obviously, the heart could not keep up its output without an equal inflow. There are at least three factors contributing to the solution of this problem: the large size of the veins as com- pared with the arteries, the squeezing action of the muscles of the body, and the sucking action of the chest during inspiration. Since venous pressure is low, one might wonder why the blood in the veins does not reverse the direction of its flow during ex- piration, especially when the intrathoracic pressure is suddenly increased as in Coughing or sneezing; the force of gravity, too, in the dependent arms or legs tends to pull the blood away from the heart. In order to prevent the occurrence of retrograde blood ſlow, some veins are supplied with valves. These are small cuplike projections which are held against the wall of the vein as long as the blood moves toward the heart. Iſ the flow begins to reverse, the lumen is closed by these delicate valves which are filled by the ſlow of blood, much as an umbrella is filled out by a sudden gust of wind. Retrograde flow does not occur when the valves are Competent. Despite the wide distribution of the blood in the capillary vessels throughout the body, a supplemental network is necessary. The chief arteries and veins might be likened to the highways which connect great cities; the capillaries would then represent the main street of a city. Not every resident lives on a main street, however; and not every cell of the body is situated along the wall of a capillary. Each Cell, nevertheless, must receive its share of the chemicals carried by the blood, and must have an outlet for its products. This service is rendered by a system composed of the myriads of minute spaces between cells (tissue spaces) and the lymphatic channels with which they communicate. Lymph (or tissue juice) is a colorless fluid which in composition closely approximates blood serum. It may, in fact, be blood serum which has left the vascular system through the thin walls of the capil. laries. In any case, adequate exchange of chemicals, including DISTURBANCES: THROMBOSIS; EMBOLISM; GANGRENE 151 oxygen, takes place between the circulating blood and many of the cells of the body through the mediation of this tissue fluid. Much of the tissue fluid returns to the circulating blood through the capillary walls, but some of it collects in the tiny thin-walled lymph vessels. These are widely distributed, and the lymph ves- sels of each part of the body drain into the lymph nodes of that region. Eventually lymph is returned to the vascular system, either into the blood vessels of the lymph nodes or directly into the V6IIlS. The arteries and the veins, especially the smaller terminal ves- sels, are richly supplied with nerves. These nerves emanate from the sympathetic division of the autonomic nervous system; thus stimuli which activate the sympathetic system affect the tone of the muscle fibers in the walls of blood vessels. Stimulation of the nerves by such a drug as ephedrine causes, in most instances, contraction of the vessels, with a consequent diminution of the blood flow to the affected areas, whereas paralysis of the nerves, as by procaine, permits dilatation of the vessels with attendant increase of blood flow. An additional fact of importance, and one which is peculiar to the vascular system, is the arrangement of collateral vessels. By means of the ſrequent communications between the smaller branches of the main arteries and veins respectively, the vascular system is able in most regions to overcome the effect of an obstruction to the circulation. Thus, following the occlusion of a large artery or vein at one point, the blood may be “detoured” around the obstruction through the communicating branches above and below the obstruction. There are, however, certain regions where adequate collateral circulation does not exist, and Some arteries which are terminal arteries, the occlusion of which leaves the affected area without blood supply. The relationship between the flow of blood through the lungs (pulmonary circulation) and the flow through the rest of the body (systemic circulation) may be compared to the numeral 8, the upper loop representing the pulmonary circuit, the lower loop representing the systemic circuit, the heart being located at the intersection. It is at once apparent that all blood returning from the body is pumped into the lungs, and all from the lungs into the rest of the body. The course of blood returning from the stomach, intestines, pancreas, and spleen is unique in that the blood passes through the liver before returning to the systemic circulation. The large 152 NURSING IN VASCULAR SURGERY < 8 § 4<！} <ſ ¿?$ ſă¿<$ ğ §-§ r䧧§§ # #, # {seaae \\\\^►= <==*'，׺žyº№ŅŠÑ№te=}©SÈSÈÈèèș`S`Šº Ķ\\~~ÈNÈRÈS• e ſi §§NY)• ！ £e. ... …’ *…*. (A → FIGURE 58. Treatment of varicose veins, showing exposure and division of the saphenous vein at its junction with the femoral vein. The saphenous vein is then removed by stripping. ankle (medial malleolus). These ulcers will not remain healed while the varicosity persists, and in longstanding ulcers there is so much scar tissue formation that plastic surgical procedures are usually necessary in addition to treatment of the veins. The modern treatment of varicose veins combines ligation of the veins at or below the incompetent valves and communica- tions with the deep veins, and removal of the varicosities distal to the points of ligation, a step accomplished by stripping (see Fig. 58). These procedures can be performed under local or gen- 164 NURSING IN VASCULAR SURGERY eral anesthesia. In either case the patient is required to get out of bed and walk shortly aſter operation, and frequently there- aſter. Elastic pressure dressings are applied to the operated limbs, from toe to above the knee; these dressings are removed and re- applied when they become disarranged or loose. The patient may leave the hospital as soon as recovery from anesthesia is complete. Instructions for home care include the application of the elastic bandages, avoidance of wetting the operated legs in bath or shower until the wounds are healed, and the making of an appointment for the return visit. PHLEBITIS Since inflammation of a vein is almost always accompanied by thrombosis, the double name thrombophlebitis is often used. As elsewhere in the body, inflammation may be the result of infec- tion, or of the action of other noxious agents such as irritating chemicals, or of trauma. Oſten thrombosis and thrombophlebitis occur without any apparent cause, especially after abdominal operations; and it has been variously assumed that operative trauma, the position or the inactivity of the anesthetized patient with resultant stasis of venous blood, dehydration, or a low grade infection might be the cause. This type of phlebitis is usually found in the iliac veins and their tributaries, the pelvic and femoral veins, and is the most common source of pulmonary em- bolism. When caused by inſection or trauma, phlebitis also occurs in the upper extremities, the head, and the neck, and the abdominal cavity. Thrombophlebitis of the lateral sinus or of the jugular vein is a dreaded sequel of mastoid infection, and pylephlebitis (inſection of the portal vein) sometimes follows appendicitis. An abscess may form in a thrombosed vein. Thrombosis is sometimes ſound in the mesenteric vessels which supply and drain the intes- times. This condition obviously is very serious since gangrene oſ the intestines results. Thrombosis constitutes the first step in the process of healing the inflamed vein; nevertheless, the obstruction of the vein aug. mented by the occlusive effect of regional venospasm will seri- ously affect the venous drainage of the region. Phlegmasia alba dolens appears, as does lymphedema, since lymphatic obstruction follows venous blocking. The inflamed vein is usually very ten- der, and, if it is superficial, there will be local heat and redness. At times mild fever and other systemic symptoms appear. PERIPHERAL VASCULAR DISEASE 165 In most instances of venous obstruction the collateral vessels are able to take up the burden. When very large deep veins are affected, or when the thrombosis extends for a considerable dis- tance, the effect of the obstruction is more pronounced, and the regional swelling is greater and more lasting. The healing of phlebitis is often characterized by recanalization of the vessel with partial return of function. The occurrence of phlebitis following an operation may be suspected when there is tenderness in the calf muscles or pain there upon dorsiflexing the foot (Homans's sign), and confirmed by examination of the legs. Often the swelling is so slight as to be missed altogether unless careful measurements are made; it is help- ful iſ the circumſerence of the legs has been measured before operation. Iliac or femoral thrombophlebitis is also a frequent Complication of pregnancy. Conservative treatment is usually advocated for patients with acute phlebitis. Rest in bed, with position favoring the maximal drainage of the affected part, is advisable. This can be best achieved by elevating the ſoot of the bed 6 inches. Massage is strictly ſorbidden as there is real danger of dislodging thrombi, thus causing embolism. An additional precaution is the avoid- ance as far as possible of Sudden straining, including Coughing, Sneezing, or straining when using the bedpan. Care must be taken to avoid pressure of the bedclothes upon the affected part. The use of hot or cold applications is common, but there is little reason to believe they are efficacious. Some surgeons advocate im- mediate ligation of the vein in order to prevent embolism. When the venous drainage is affected, it is advisable to block the sym- pathetic nerve supply of the regional veins, which relaxes veno- spasm and not only improves the circulation but also relieves pain. Anticoagulant therapy is thought by some surgeons to be useful in limiting the extent of the disease. Healing may take place with disappearance of all symptoms, but often the venous obstruction persists and permanent damage follows. Probably the most useful measure in treating postphle- bitic swelling of an extremity is tight bandaging accompanied by exercise. Proper care of this sort in the early stages may prevent such sequelae as varicosities and ulceration. ARTERIOSCLEROSIS “Hardening of the arteries,” as this condition is known to the layman, is found in many people over 40. The cause is as yet 166 NURSING IN VASCULAR SURGERY unknown. The walls of arteries become thick, inelastic, Scarred, and even calcified, resulting in serious impairment of the periph- eral circulation. Since the disease generally affects the whole arterial tree, the collateral vessels are damaged too. Arterio- sclerosis, moreover, is a progressive disease. Although vascular damage occurs anywhere in the body, the surgeon is chiefly Con- cerned with sclerosis of the arteries supplying the legs, because this is a Common cause of gangrene. The usual symptoms are coolness and discoloration of the toes and feet and Cramps in the legs. The Cramps come on character- istically after walking a short distance, and disappear upon rest- ing (intermittent claudication). This symptom is due to the nar- rowing of the arteries so that the blood supply to the muscles of the legs, which is sufficient during rest, becomes inadequate during exercise when the muscles need an increased blood flow. Examination of the legs may show all of the manifestations of deficient arterial supply, and usually the superficial arteries feel hard and do not pulsate. Calcification of the vessel walls is often apparent in X-ray films. The foot is usually no warmer than room temperature, and does not warm up when attempts to produce vasodilation are made. Vasospasm is present in arteriosclerosis, but in advanced cases there is so much organic damage that little or no relaxation is gained by interruption of the nervous control. In patients having severe sclerosis, frank gangrene of toes or foot appears. For many years the frequent observation of gangrene of the lower extremities in patients having diabetes mellitus fostered the belief that the diabetes caused the gangrene. It is known now that the so-called diabetic gangrene is due to arteriosclerosis, which in patients with diabetes occurs at a younger age and progresses more rapidly than in those without diabetes. Circula- tory disturbances in patients having diabetes are the more serious because of the lower resistance to infection which is always asso. ciated with diabetes. The treatment of legs with impaired circulation as a result of arteriosclerosis consists in attempting to improve the collateral circulation and in preventing damage from external causes such as trauma or infection. The activity of the patient must be re. stricted to that amount which can be accomplished without caus. ing symptoms. In the early stages some of the circulatory impair. ment is due to vasospasm, and in patients in whom this can be PERIPHERAL VASCULAR DISEASE 167 demonstrated a sympathetic block (lumbar sympathectomy) is helpful. The appearance of gangrene signifies failure of the circulation, and removal of the dead portion is indicated. Occasionally this process is limited to the loss of a toe or two, but when most of the foot is gangrenous, experience has shown that amputation at a higher level may be necessary in order to make sure that the tis- sues at the site of operation have enough circulation to heal. THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE) This disease is characterized by an inflammation of arteries and veins. All the usual features of inflammation may occur, in- cluding severe pain, tenderness, and circulatory disturbance as a result of both thrombosis and severe vasospasm. The cause of this disease is unknown. In contrast to arteriosclerosis, Buerger's dis- ease affects relatively young persons, usually men of 20 to 35. It is uncommon in women. Healing occurs following the period of acute arteritis and phlebitis, and the ultimate Condition of the circulation depends upon the amount of vascular damage and the number of collateral vessels which have escaped the inflam- mation. In most cases there is residual pain and circulatory im- pairment varying from minimal Cramps and Coolness to gangrene. The vessels of the legs are more commonly affected than those of the arms. Treatment is designed to relieve the symptoms, to bring about favorable conditions for healing of the vessels, and to improve the circulation. Since much of the pain and circulatory disturb- ance is due to vasospasm, the operations which interrupt the nervous control of the diseased vessels (sympathectomy) are often effective. Thromboangiitis obliterans was once known as the “tobacco Smokers' disease” because many patients suffering from it were heavy smokers. It is not likely that tobacco smoking causes the disease, but it is certain that nicotine produces vasospasm and ag- gravates spasm already present. Patients who have vascular dis- ease, therefore, should never Smoke. RAYNAUD’S DISEASE Curiously enough, this disease usually affects the vessels of the arms and hands, and is more common in young women. The cause is not known, nor are any pathologic alterations of the ves- sels found. Vasospasm is the sole feature of the disease and to it 168 NURSING IN VASCULAR SURGERY may be ascribed all of the symptoms and signs. Coldness and cyanosis of the hands, particularly in cold weather or when the patient is under some nervous strain, appear early. Pain and severe circulatory deficiency of the fingers occur later; loss of nails and gangrene of the fingertips are not uncommon. In some pa tients there is thickening of the skin of the body (scleroderma), a condition thought to be related to the vasospasm. As might be expected, operative interruption of the sympathetic nervous control of the vessels relieves the symptoms and prevents further progress of the disease. The vasospasm of Raynaud's disease can be relieved in some patients by the use of drugs which inhibit or paralyze sympathetic nervous system activity. SCALENUS ANTICUS SYNDROME Symptoms similar to those of Raynaud's disease are sometimes caused by the presence of a cervical rib. This congenital abnor- mality pinches the subclavian vessels and the brachial plexus, causing circulatory deficiency and neurologic disturbances in the arm and hand. A similar picture may result ſrom spasticity of the anterior and middle scalene muscles in the neck. Cure in either case results from the surgical division of these muscles, and it is not necessary to remove the rib. NURSING CARE IN CIRCULATORY DISTURBANCES In dealing with an extremity suffering from impaired circula- tion it is important to realize that trauma is poorly tolerated and that healing is difficult. Resistance to bacterial invasion is low. Cleanliness aids in compensating ſor the lowered resistance to bacterial invasion, but the methods employed must be so gentle as not to injure tissue. Scrubbing must be avoided. Maceration of the skin leads to inſection, and must be prevented by keeping the extremity dry. Alcohol is useful for this purpose, and should be applied after the limb has been gently bathed with mild soap and Water. Particular care should be taken of the nails, and of the spaces between the toes, in order to avoid the creation of portals of entry for infection. A defective circulation cannot compensate ſor sudden changes in temperature; thus the extremity is more susceptible to burn- ing and freezing. No precaution must be neglected in protecting the limb rendered fragile by disease; chilling even a limited part of the body will produce vasoconstriction. In cold weather warm gloves and proper protection for the head, ears and neck are PERIPHERAL VASCULAR DISEASE 169 imperative. Woolen socks and comfortably fitting shoes loosely laced are best for the ambulatory patient. The patient should be taught methods. to produce generalized vasodilation such as immersion of the arms in water heated to 109° F. twice daily, or the application of a heating pad to the abdomen for thirty minutes twice a day. Simple exercises which increase the circulation are: elevation of the feet for one minute, a horizontal position, with toes and ankles flexed, for three min- utes, and the legs dangling over the side of the bed for two min- utes. A patient with thromboangiitis obliterans should be en- couraged to drink three or four liters of water daily to increase the blood volume and reduce the viscosity of the blood. Explicit directions should be given concerning the diet. A vitamin-high diet including large amounts of fresh uncooked fruits and vegetables, milk, and butter is essential. Elevation of the extremity to the level of the heart favors the circulation. There should be no constricting bands or clothing. Support of the limb must be adequate without local pressure points which might result in ulcers. An even, warm temperature should be maintained. An electrically heated cradle may be used to accomplish this, provided care is taken not to burn the patient. In summer, an ordinary Cradle may be used to keep the bed- clothes off the legs and feet. Massage is ſorbidden, because not only is there danger of loosening thrombi, but the skin, which is now less resistant, may be damaged. The morale of these patients is often very low because they 'have much pain and have usually been ill and incapacitated for a long time. Improvement, furthermore, takes place slowly, and the nurse must support the patient's will to recover. Smoking is not to be tolerated, but other possible forms of diversion short of the use of narcotics should be encouraged. Drug addiction is a com- plication to be avoided iſ possible. Careful observation as to which drugs or combinations of drugs are most effective is helpful in reducing the total amount necessary. SURGICAL PROCEDURES Perhaps the simplest and earliest operation performed on a blood vessel was phlebotomy (venesection), a procedure only oc- casionally used now. It was easy for the surgeon to incise a vein, but the patient did not always profit by the subsequent loss of blood. The ancients also knew how to stop the flow of blood 170 NURSING IN VASCULAR SURGERY by tying a thread (ligature) about a vessel, but this relatively simple operation, called ligation, was first put on a sound basis by Larrey, the surgeon of Napoleon's armies. It is now one of the essential procedures of operative surgery. - Although it was truly a great advance when surgeons learned to save life by ligating a bleeding artery, further steps have been taken. A successful technic has been devised for suturing a wound in a vessel, and also for bringing together the divided ends of a severed vessel (anastomosis). More recently it has been found possible to transplant portions of arteries and veins to replace segments of injured or diseased vessels; indeed portions of arteries may be frozen by special technics and preserved in readi- ness for use when needed. AMPUTATIONS The surgical removal of a part or all of a limb is not primarily an operation upon the vascular system, but it is discussed at this time because it is frequently necessitated by the presence of gangrene. A proper amputation removes no more of a limb than is necessary, and yet is designed to leave nothing which may re- & quire further surgical treatment. The level of amputation for gangrene is determined by the condition of the circulation, for it is essential to place the operative wound in viable, healthy tissues. The surgeon must also take into account such technical considerations as the formation of a stump which can bear weight painlessly and which will be so placed as to enable the patient to make the most effective use of an artificial limb (prosthesis). The simple guillotine or circular amputation is performed when infection is present, as in moist gangrene, or when con tamination is inevitable, as in modern war. In this operation a circular incision is made, and skin, muscles, and bone are di- vided at the same level. Blood vessels and nerves are ligated but no attempt is made to close the wound. As might be expected, healing is prolonged in this type of amputation and secondary Operations are usually necessary; but the tissues have a better opportunity of overcoming infection, drainage is free, and there is no chance for the growth of anaerobic bacteria. It is in this last kind of situation that refrigeration of the extremity proves its value. If this technic (described on p. 31) has been used, the amputation is performed while the extremity is being permitted to thaw out, and no other anesthesia is neces- sary. ~ Circumstances permitting, a plastic type of amputation is far PERIPHERAL VASCULAR DISEASE 17] lncisions in skin (a) and bone (b) § §es, a ޺ºkin 11ap %2. §º ==º º \ | | | Wg s ޺ vassals and y º Wººs § º X*}|\g ſ § § % º / %) § &Nº | & Whº. %’s tº: FIGURE 59. Thigh amputation. more satisfactory. The incision is designed to provide appro- priate skin flaps. The bone is resected at a level slightly higher than that at which the muscles are divided, and the anterior and posterior groups of muscles and tendons are brought to- gether over the bone end. The skin flaps are sutured in such a way that the scar is remote from the region intended for weight bearing. Blood vessels and nerves are dealt with as in the guil- lotine type of amputation. Nursing Care. To lessen edema and for Comfort, the stump is elevated on a pillow after operation. Because oozing, and perhaps bleeding, will occur, it is advisable to protect the pillow with a rubber case. Many surgeons require that the stump be kept in full sight from twenty-four to forty-eight hours after operation to eliminate a failure to discover a sudden hemorrhage. A tour- 172 NURSING IN VASCULAR SURGERY niquet should always be instantly available. It is convenient to have it tied to the foot of the patient's bed. If the patient is incontinent of urine or feces the dressing should be Covered with a waterproof substance, such as waxed paper, rubber tissue, or oiled silk, secured around the leg above the stump with adhesive to prevent contamination. Skin traction is applied to the limb after a guillotine amputation to pull the skin down over the stump. The traction may be rigged up with a pulley and a weight, or it can be more simply arranged by the use of a Thomas splint with elastic traction or a turnbuckle fastened to the distal end of the splint. This latter arrangement permits greater free- dom of motion; in fact, it is then possible for the patient to be allowed out of bed without discontinuing traction. Occupational therapy is useful in diverting the patient's attention during Con- valescence and in restoring his morale. Operations upon the blood vessels, including amputation, are occasionally complicated by severe hemorrhage. This may occur in the first few hours after operation, sometimes as a result of the breaking of a ligature or a suture. Immediate application of a tourniquet or pressure bandage is indicated; and if the bleeding is severe, exploration of the wound should be carried out so that the bleeding vessel may be ligated securely. Hemorrhage may also take place several days after operation; this is usually due to infection, with erosion of the vessel wall or of the thrombus. The treatment is the same as for immediate postoperative hemor- rhage. A dreaded complication of amputation for gangrene is infec- tion with the anaerobic gas-forming Welch bacillus. Sudden ſever and acceleration of pulse rate should warn the surgeon of the Onset of such an infection. Because of the relative fre- quency of infections, antibiotic therapy is used routinely as a prophylactic measure. Rehabilitation of the Amputee. In civilian life the patient who has undergone an amputation usually is discharged from the hos- pital as soon as the wound is healed, so that most of the job of rehabilitation must be carried on during his convalescence at home. This is in contrast to the practice in the hospitals of the Veterans Administration and of the Armed Forces; in those fa- cilities the patient receives care as an impatient until maximum benefit is achieved. Good results can be obtained by either method, although the latter is more costly. The goals to be achieved are: (1) convincing the amputee that he can and must make the effort to accept his misfortune and PERIPHERAL VASCULAR DISEASE 173 overcome his handicap; (2) teaching him to use his prosthesis; and (3) training him, if necessary, in a new vocation by which he can earn a living. It is the first of these goals with which the nursing personnel is mainly concerned, as specialists usually take over the actual training program which begins when the wound is healed. Most patients are badly depressed immediately after an am- putation. Doctor and nurse alike must encourage the patient, always emphasizing the achievements which it is possible for the patient to realize and stressing the necessity for effort on the part of the patient. As rapidly as possible the patient is encour- aged to become self-reliant, so that he can see for himself that he will not be permanently dependent, or an object of pity. Learning to move himself about in bed, giving his own bath, getting from bed to chair, and the like are devices to be utilized. In discussing the future, the subject of goals that can be attained should be handled in a realistic manner, and individualized to suit the patient. It is amazing to observe how well young patients can adjust to the situation and how they can overcome severe handicaps; older patients, as might be expected, do these things less well and it is better not to plan too ambitious a program for them. SYMPATHECTOMY The treatment of vasospasm in association with vascular dis- ease requires surgical attack upon the sympathetic nervous sys- tem, in order to divide the nerves which carry the impulses causing spasm. To relieve vasospasm in the arm, for instance, it is necessary to divide the sympathetic fibers which lie along the upper thoracic vertebrae (dorsal sympathectomy). For vasospasm of the leg, lumbar sympathectomy is performed. Dorsal Sympathectomy. Incision is made between the spine and the scapula on the affected side, and a small portion of the second rib is removed. The sympathetic ganglia and nerves can then be exposed and divided. A frequent complication of dorsal sympathectomy is perforation of the pleura with consequent collapse of the lung. Cyanosis, dyspnea and fever should be re- ported to the surgeon. Upon regaining consciousness the patient may complain of severe pain because of trauma to the pleura. Opiates are given to relieve this distress. Frequent turning and Coughing help to prevent pneumonia. Lumbar Sympathectomy. This is the operation performed for the relief of vasospasm of the leg. Through a small lateral ab- § k 174 NURSING IN VASCULAR SURGERY dominal incision, dissection behind the peritoneum proceeds until the sympathetic ganglia lying along the lumbar vertebrae are exposed. The lumbar ganglia are removed and the fibers di- vided. When the operation is correctly performed the peritoneal cavity is not opened, and thus some of the complications at- tendant upon laparotomy may be avoided. There is often dis- comfort beginning the day after operation because of abdominal distention. This may be relieved by an enema followed by hourly intramuscular injection of 0.3 mg. of Prostigmin for three doses, and by the passage of a rectal tube. Hourly turning should be encouraged to prevent further distention. Sympathectomy for Relief of Essential Hyperfension. This is carried out in the same manner, although the surgeon attempts to interrupt the sympathetic fibers of the vessels of the abdomen as well as those of the extremities. Essential hypertension is a highly fatal syndrome, the cause of which is not known. It attacks those in the third and fourth decades of life, and is characterized by a progressive elevation of the blood pressure. Since stimulation of the vasomotor nerves causes constriction of the peripheral vessels, resulting in a rise in systolic blood pressure, it seemed likely that the interruption of the vasomotor fibers might per- mit lowering of the blood pressure. When this can be accom- plished, progressive and irreparable damage to the kidneys, peripheral arterioles, heart and brain may be prevented or post- poned. The right and leſt sides are usually denervated in two stages; the second operation is performed eight or ten days after the first. Nursing Care. The patient with malignant hypertension has been carefully selected by physician and surgeon as being a suitable candidate for operation. Such a patient should be kept on bed rest and every attempt should be made to provide a pleasant and relaxing atmosphere; a private room away from the noise and distractions of a busy ward is helpful. Good preopera. tive care also necessitates that the nurse take the time to dis- cover the fears and worries of the patient. Encouraging him to talk, and listening attentively, will win confidence and release tension. A tactful question injected into the conversation, every now and then, may help the patient to unburden himself. The nurse will find that she really needs to say very little and that reassurance comes to the patient when he can “talk things out.” The immediate preoperative preparation is the same as that for any patients being prepared for general anesthesia. PERIPHERAL VASCULAR DISEASE 175 } Upper thoracic sympathectomy ( Č X # ! i Thoracolumbar sympathectomy | bº Lumbar sympathectomy { º C- º s | B- Žs Q 2 2 s i º S-2 FIGURE 60. Diagram of sympathetic ganglia to show location of sympathec- tomies performed to relieve vasospasm of extremities and to relieve hypertension. Following operation, the patient is usually placed in the lateral position and, when the blood pressure is low, shock blocks are placed under the foot of the bed. Frequent reading and recording of the blood pressure, pulse, temperature and respirations are essential. The large incision in the back and the trauma to the pleura are the cause of the severe pain which the patient in- variably has upon reacting from the anesthesia. Morphine or 176 NURSING IN VASCULAR SURGERY other analgesics should be administered to relieve this distress. Encouraging the patient to cough, breathe deeply and turn are essential in preventing atelectasis and pneumonia. Since there is often a profound drop in blood pressure which is accompanied by faintness, dyspnea and dizziness when the patient is placed in an upright position, it is wise to test his reaction and accustom him gradually to the sitting position. High Fowler's position should be attempted several times each day, beginning several days after operation. The day before the patient gets up he should sit on the edge of the bed with his legs dangling. He should be taught that a quick change from the prone to the upright position will usually result in dizziness and faintness for some time after operation; by moving slowly and dangling he may avoid this discomfort. Symptoms of faint- ness always disappear when the patient lies down. Dizziness and shortness of breath are relieved by walking but may return when the patient stands still for only a few minutes. Various methods may be used to lessen these symptoms. The application of elastic bandages from instep to knee may prove effective but in severe cases a girdle or abdominal binder should also be worn. Additional support may be gained by wearing a piece of sponge rubber, 3 by 5 inches, over the lower abdomen in- side the girdle. The leg bandages are usually discarded aſter a few weeks, but the girdle is often left on for several months. Girdle neuritis occurs at times and may last several weeks. Anal. gesics are usually given according to the severity of symptoms. Throughout the postoperative period the nurse should in- struct the patient in self-care suitable to his particular needs. On leaving the hospital, he should ſeel confident that he is able to control the uncomfortable symptoms by understanding what to do. Both the physician and surgeon will take part in the ſollow-up care of the hypertensive patient, which is a long-term problem that requires regular evaluation and attention to old and new Symptoms. SUMMARY In general, the effect of peripheral vascular disease is to de- prive the part of the body served by the diseased vessels of ade- quate circulation of blood. Surgical procedures are directed first at improving the ſlow of blood; ſailing in this objective, surgery is then employed to remove the dying or dead tissue. Good SURGERY OF THE HEART AND GREAT VESSELS 177 nursing care includes the instruction of patients in self-care, the prevention of narcotic addiction, aid to patients in giving up the use of tobacco, and much attention to morale building and rehabilitation as many of these patients will have a permanent disability to which they must adjust. VOCABULARY REVIEW aneurysm ligation guillotine varicosity sympathectomy thromboangiitis thrombophlebitis amputation obliterans claudication prosthesis SUGGESTED READING 1. Fedder, Helma: Nursing the Patient with Sympathectomy for Hypertension. Am. J. Nursing, 48:643–644, 1948. 2. Glover, John R. The Major Amputations. Am. J. Nursing, 50:544–549 (September) 1950. 3. Here's an Idea: Am. J. Nursing, 50:555 (September) 1950. 4. Moskopp, Mary-Elizabeth, and Sloan, Joan: Nursing Care for the Amputee. Am. J. Nursing, 50:550–555 (September) 1950. 5. Spinney, Jean McDonald: Buerger's Disease. Am. J. Nursing, 49:119–122 (February) 1949. 6. Swan, Marguerite: Leg Amputation with Refrigeration Anesthesia. Am. J. Nursing, 47:415-416 (June) 1947. 7. Smithwick, Reginald H., and Kinsey, Dera: Surgical Treatment of Hyper- tension. Am. J. Nursing, 47:153–155 (March) 1947. CHAPTER 17 Surgery of the Heart and Great Vessels Enveloped completely in the pericardial sac, the heart is situated in the lower midportion of the thorax (inferior mediastinum). It is not diſficult to expose the heart surgically, but in order to do so it is necessary to open the chest. All of the considerations dis- cussed in connection with thoracotomy (Chap. 11) are therefore applicable. 178 NURSING IN VASCULAR SURGERY CONDITIONS REQUIRING CARDIAC SURGERY Heart Wounds. The treatment of heart wounds has proved to be a successful field of cardiac surgery. A large wound of the heart causes death very rapidly, either from loss of blood ex- ternally or into the pleural cavities, or from disorganization of the heart action. If, on the other hand, the opening in the peri- cardial sac is small, blood pumped out of the heart wound is confined within the sac; the amount of blood lost is thus limited, and death does not occur at once. As the blood accumulates in the pericardial sac, however, the heart is compressed (cardiac tamponade), producing the classic triad of low arterial pressure, high venous pressure, and a quiet heart. Unless the compression of the heart is relieved, the cardiac action becomes progressively feeble and finally ceases. Rapid diagnosis and immediate treat- ment are needed. Tamponade is relieved by evacuating the blood from the pericardial sac. Unless vital portions have been dam- aged, wounds of the heart heal readily when sutured in the proper manner. Pneumothorax, hemothorax, and laceration of the lung and intrathoracic vessels often accompany heart wounds, having been produced by the same agent (e.g., stab or gunshot) and must be dealt with as outlined in Chapter 11. The need for large transfusions is obvious. Cardiac Standstill. Occasionally during the induction of gen- eral anesthesia, or during the course of an operative procedure the normal rhythmic contractions of the heart cease, presumably due to a sudden failure of the intrinsic nerve impulse conduction system of the heart. When this occurs, the flow of blood abruptly stops and anoxia rapidly develops; without oxygen, the cells of the brain are irreparably damaged within five to ten minutes and death ensues. In many instances, the heart beat can be restored and the life of the patient saved by prompt action. The heart is quickly exposed by an incision through the chest wall, or through the diaphragm if the abdomen is already open, and the surgeon massages the heart carefully and rhythmically. This, if done properly, restores the flow of blood and relieves the anoxia. Oxygen and artificial respiration are usually administered by the anesthetist. Procaine may be injected into the heart, and elec- trical stimulation may be necessary. Often the rhythmic contrac. tion returns spontaneously after a few minutes of massage. Cardiac massage is not invariably successful, and there is a high mortality rate in Cardiac standstill. Sometimes the heart beat is restored after an interval which is longer than the survival time SURGERY OF THE HEART AND GREAT VESSELS 179 of the cells of the brain which have been deprived of oxygen; then consciousness is not regained although the patient may live for some time. Many hospitals keep on hand special equipment for dealing with this emergency, including Oxygen equipment, sterile instru- ments for opening the chest, electrical stimulating equipment, the necessary drugs and Syringes, and electrocardiographic equip- IſleIlt. Acufe and Chronic Pericardifis. Many Cardiac Conditions once considered exclusively medical in nature are now being attacked surgically with success. Surgical drainage should be performed in cases of acute suppurative pericarditis, just as in any pyogenic inflammation. There have not been many cures, chiefly because patients with suppurative pericarditis also have other and less favorable lesions. Chronic constrictive pericarditis, on the other hand, offers a better chance of surgical cure. In this condition the action of the heart is badly hampered by thick scarring and cal- cification of the pericardium, the result of the healing of a peri- cardial inflammation, usually secondary to rheumatic fever Or tuberculosis. The surgical removal of large portions of the scarred pericardium liberates the heart, permitting it to expand and contract effectively. The operative mortality is high, but the risk is justified since the untreated patient faces certain death after months of invalidism, while the successfully treated patient may return to a normal life. Congenital Heart Lesions. Pulmonic Stenosis. A brilliant recent advance has been made in extending the benefits of surgery to “blue babies,” who, as a result of a congenital malformation of the heart which does not permit adequate circulation of the blood through the lungs, suffer from insufficient oxygenation of the blood. The most common variety of malformation is the tetralogy of Fallot; there are four defects in the heart but the most important is the narrowing of the orifice of the pulmonary artery (pulmonic stenosis). The children who have this con- genital abnormality do not grow properly and are doomed to an early death unless successfully treated surgically. They are cyanotic, cannot tolerate exertion; blood studies show a high red cell count (polycythemia) and a low degree of oxygen content. In 1945, Blalock and Taussig reported the first successful re- sults obtained by performing an operation they devised to shunt the blood around the narrow pulmonary orifice. One of the large branches of the aorta, usually the right subclavian artery, is 180 NURSING IN VASCULAR SURGERY R. Carotid | L. ** zºodlavian & Innominate a. Pulmonary. slenośls. L. pUlm. a. El tº *) \, ={ º #s # sº-º-º-º: == E º: EE #, =} ESS Nº. FE. - E- º º FIGURE 61. Diagrammatic sketch of heart and great vessels of “blue baby. (By permission of Surgery, Gynecology and Obstetrics.) connected (anastomosed) to the pulmonary artery. The imme- diate result is dramatic, with rapid disappearance of cyanosis and intolerance to exercise. The late results are equally impressive. Thousands of children all over the world who would have been dead without operation are now leading relatively normal lives, growing and developing properly. SURGERY OF THE HEART AND GREAT VESSELS 181 R. Common Carotid ArtS L. Common Carotid Art. R. Subclavian Art ; S. & ---------- ~~~~~~ *s |-- * Art. L. Pölmonary Art. FIGURE 62. Blalock operation: leſt subclavian artery anastomosed to left pul monary artery. (By permission Journal of the American Medical Association.) Patent Ductus Arteriosus. A second common congenital cardio- vascular malformation is a persistent patent (open) ductus ar- teriosus. This structure, which is a large, open communication between the aorta and the pulmonary artery, is present normally in the ſetus to permit the circulation of blood which is oxygen- ated in the maternal placenta rather than in the nonfunctioning lungs of the fetus. The ductus normally closes during or shortly after birth, but in some individuals it remains open perma- nently. In the past, most of these unfortunates died young, but the outlook has been changed completely by the success of mod- ern surgery. The patent ductus is ligated; the results have been excellent. Coarctation of the Aorta. In this congenital lesion, the thoracic aorta is narrowed or closed. Usually, the narrowing involves only a very short segment. The patient who has this condition suffers from elevated blood pressure (hypertension) in the upper part of the body, and low blood pressure (hypotension) in the lower portion of the body. The treatment consists in removing (resect- 182 NURSING IN VASCULAR SURGERY PATENT overus’t. ARTER1OSUS º FIGURE 63. Steps in ligation of patent ductus arteriosus. ing) the narrowed segment and performing an end-to-end anas- tomosis of the aorta. The mortality of the operations is now rea- sonably low and the result highly satisfactory. Although coarcta- tion is a congenital lesion, the symptoms do not make themselves known, as a rule, until the patient is in the second or third decade of life; without operation, few of these patients live beyond 30 years of age. Surgery of Acquired Valvular Heart Disease. Rheumatic fever, syphilis, and bacterial infection often leave damaged heart valves in their wake. The valves become thick and narrowed, and usu- ally leak. Direct surgical attack is now being made on these dis- eased valves in patients who otherwise would die of cardiac failure. The best results thus far have followed surgical treatment of mitral stenosis. In one technic, the surgeon introduces his ſinger into the heart and dilates the valve; in another technic, a punch instrument (valvulotome) is inserted into the heart and a portion of the diseased valve cut away. Portal Hypertension. Obstruction to the flow of blood through the portal vein from the stomach, spleen, and intestines to the liver (and ultimately into the vena cava) results in elevation of the pressure in the portal vein and its tributaries. Cirrhosis of SURGERY OF THE HEART AND GREAT VESSELS 183 the liver is probably the most common cause of this condition; other causes are Banti's disease, and thrombosis of the portal vein. As the pressure in the portal venous system rises, the col- lateral communications into the systemic veins of the body enlarge. Among the major collateral channels are the esophageal veins and the hemorrhoidal veins. Serious hemorrhage from either source can occur, and is often a cause of death in these patients. Another complication of portal hypertension is the accumulation of large amounts of fluid in the peritoneal cavity (ascites). Following the pioneer work of Blakemore, surgeons may now perform a by-pass or shunting operation; by joining the portal vein or one of its major tributaries to a systemic vein, a way is opened for the blood to by-pass the obstruction in the liver. Por- tacaval anastomosis (joining the portal vein and the inferior vena cava) relieves the portal hypertension and its complica- tions, but, when the hypertension is due to cirrhosis, the under- lying disease of the liver usually continues unchecked, the patient ultimately succumbing to hepatic insufficiency. NURSING CARE IN CARDIAC SURGERY The patient who is a candidate for cardiac surgery has usually spent many days at the hospital as an outpatient while physical examination, blood studies, fluoroscopy, x-rays and electrocardio- gram were done. In addition, in some patients, heart catheteriza- tion' and angiocardiogram are carried out. For either of these procedures, the patient is usually admitted to the hospital. Heart Catheterization. Preparation for heart Catheterization or angiocardiogram consists of withholding fluids and food for two hours prior to the treatment to prevent nausea and subse- quent vomiting. Morphine and scopolamine are administered about twenty minutes before the patient is taken from the ward. Iſ there is restlessness during the procedure Nembutal is usually given. Patients are occasionally given general anesthesia but usually the previously mentioned sedation suffices. The nurse has had only a brief time to make friends with her patient, frequently a child, and it is often rather difficult to win full cooperation. She usually gives very few explanations concern- ing his treatment when he is under 5 years of age unless the questions which he asks indicate that he is able to understand. To the older child, the nurse explains simply and in a matter- 1 See Brown, pages 264-265. 184 NURSING IN VASCULAR SURGERY of-fact manner that he will have pictures taken of his chest, that blood tests will be done, and that he will ride on the stretcher to see the doctor. If an adult, she questions him to find out if he understands what will be done. After the patient returns to the ward the temperature, pulse and respirations are observed for any irregularities and, if so, the doctor should be notified. Nausea may occur following the procedure. To minimize vomiting, fluids and food are withheld for about two hours. Such a patient is usually discharged from the hospital but may return later after a complete evaluation has been made of all the findings and the cardiologist has recommended him for Surgery. Preparation for Operation. When the patient is admitted for surgery, the nurse should familiarize herself with his history as shown on the chart, giving special attention to the description of the patient's attributes, habits, interests and limitations. Repe- tition of details already given may be disheartening and discour- aging to the patient or family, suggesting a lack of Coordination within the institution. Therefore the plan of care of the patient should be based on information received from the history with such additional details as are volunteered by the family and the patient. The anxiety and problems of the patient and his family must be recognized by the nurse. Friendliness and patient listening will do much to foster confidence and peace of mind. The sur- geon responsible for the care of the patient has talked to the family and explained the operative treatment in full detail, but if the nurse is questioned concerning technics she should again refer the family to the surgeon to promote a better understand- Ing. Preoperative treatment consists of protecting the patient from inſection, ſorcing fluids to an adequate intake and in establishing a friendly relationship between the patient and the ward per- sonnel. It is desirable that the nurse who is to give the post- Operative care learns to know him best. The immediate preoperative care consists of the usual treat- ment with special emphasis on the provision of a good night's sleep. Nembutal administered the evening before operation not only induces sleep, but also lessens tension and anxiety the morning of operation. Water is given until only a few hours before operation; the adequacy of the intake must be watched, SURGERY OF THE HEART AND GREAT VESSELS 185 especially when the patient has polycythemia. In the morning, it is usually inadvisable to have parents see the child because of the transmission of fear and apprehension that would inevitably take place; however, each patient must be considered individually and no general routine applies to all. Sometimes provision can be made for the parents to see the child without him seeing them. In other cases, the child has adjusted well enough to his new situation so that a visit from parents would not increase his anxiety. The wishes of an adult patient should be respected as should those of his family. They find comfort in each other's company and the time of waiting to go to the operating room passes quickly while they visit with each other. It is desirable for the patient to remain in bed because the sedative administered the night before may cause dizziness if the patient gets up. Also the effects of the drug in allaying anxiety will be prolonged if activity is kept at a minimum. Posfoperative Care. In general, the preparation to receive all patients following Cardiac surgery and their immediate care is similar. In addition to the usual postoperative unit, the follow- ing equipment should be available: I. Oxygen tent 2. Suction machine, tray with No. 10 and No. 12 French catheters, and con- tainer with sterile water . Sterile water-seal drainage bottle, rubber tubing and glass connecting tubes . Stethoscope and sphygmomanometer . Standard equipment for intravenous therapy, intravenous saline and 5 per cent glucose 6. Emergency medicine tray containing caffein sodium benzoate, adrenalin, aminophylline, Digalen, sterile needles and syringes, solution for clean up, tourniquet and adhesive tape 7. Arm board and padded restraint to restrain leg into which intravenous is running 8. Steam inhalator 9. Shock blocks : When the patient returns to the ward, the nurse should read the report of the operative procedure and the record of fluids and medications given, and should observe his general condi- tion. The doctor's orders should be read carefully and carried out. The use of oxygen, usually ordered by tent, will aid in slow- ing the heart and respiratory rates. The temperature in the tent should be maintained between 68 and 70° F. and the concentra- tion of oxygen should be at least 50 per cent. 186 NURSING IN VASCULAR SURGERY The patient is usually under light anesthesia, and therefore semiconscious on arrival from the operating room; the nurse should, at her earliest convenience, restrain the foot to insure against the dislodgement of the continuous intravenous infusion which was started in the operating room. Further restraint is not advised and is seldom necessary. Thereafter the nurse counts the patient's pulse and respirations, noting the volume, regularity and rate of the pulse, the depth, ease, rate and rhythm of respirations. These are usually taken and recorded every fiſteen minutes for two to four hours, then every hour. It is suggested that the femoral pulse be taken when- ever possible because it is more accessible when the patient is in a tent, it prevents oxygen leakage, is frequently more easily obtainable and is less disturbing to the patient. Dyspnea, increased respiratory rate, grunting respirations, pain on inspiration, cyanosis or increase oſ cyanosis and flaring at the nostrils are symptoms which should be watched for; when these occur the doctor should be notified. The blood pressure is usually taken every half hour for six hours, then every hour for six hours and thereafter according to order; this will depend upon the condition of the patient and the nature of the operation. If the patient is in an oxygen tent, the nurse takes the pressure on the arm the first time and checks it on the leg in the popliteal space at the same time. Iſ the readings are almost the same, the pressure may be taken on the leg thereaſter unless it becomes unstable, in which case it should be checked on the arm. The instability of the blood pressure should be reported to the doctor. The temperature is taken every hour ſor at least two hours and thereafter every four hours iſ there is no ſever. However, when whole blood has been administered it should be taken every hour for four hours after the treatment is started. Any rise or fall of over a degree, either sudden or gradual, should be re- ported. The next observation is the patient's state of consciousness. A quick response is desirable; when the patient does not respond within an hour after operation the doctor should be notified. The movement of extremities should be checked carefully. Iſ there has been cerebral damage as the result of cerebral throm- bosis during the operation hemiplegia may be present. Paralysis may occur in varying degree. The nurse should ask the patient to Squeeze his hands, show his teeth, and wiggle his toes, in order SURGERY OF THE HEART AND GREAT VESSELS 187 to elicit abnormal signs. Any deviation of the eyes should also be noted. The dressing should be observed frequently for bleeding. The drainage ſrom the catheter in the chest should be observed and the apparatus cared for exactly as described on page 118. Turning and coughing are encouraged for all patients every hour for the first twelve to twenty-four hours. Mucus is removed by suction and, iſ coughing is not sufficiently ſorceful, endo- tracheal suction is indicated. The nurse can help the patient greatly in lessening the pain of coughing if she exerts some pres- sure with the palm of her hand over the operative area. When the mucus is very tenacious, steam inhalations are ordered; this makes the mucus less viscid and allows easier expectoration. The patient is usually kept flat in bed for the first day, or until the blood pressure is stable. After this, he is frequently more comfortable with the head of the bed raised to a 20 to 30 degree angle. Infrequently laryngeal edema occurs. This is characterized by labored respirations having a wheezing, Crowing sound and signs of inspiratory retraction of the chest. Tracheotomy may be necessary. An adequate fluid intake is important. The surgeon orders the amount of intake that he desires the patient to have within twenty-ſour hours. Since the patient receives intravenous fluids until he is able to take by mouth the ſull amount ordered, the nurse must keep careful check on the amount of fluid the patient receives by all routes. Furthermore, the nurse must know the amount that the patient should receive by mouth and vein each hour. When the patient increases his amount by mouth, the drops per minute of the intravenous infusion should be reduced accordingly or vice versa. Allowing the patient more fluid than is ordered may result in pulmonary edema and cardiac decom- pensation. Water in small amounts, 30 to 50 cc., should be offered each half hour soon after the patient reacts from anes- thesia. Other liquids and solid foods are added when the patient seems able to tolerate them. The output of urine is carefully measured and recorded. A de- Creased amount is an early sign of Cardiac decompensation. Pul- monary edema is characterized by dyspnea, Orthopnea, wheezing respirations, cyanosis and frothy sputum. The site of the intravenous cannula should be observed closely for swelling, redness, heat and pain; these signs may indicate 188 NURSING IN VASCULAR SURGERY the onset of infection or phlebitis, and should be reported to the doctor. Antibiotics and ascorbic acid are usually administered to all patients to prevent infection and aid healing. Pain in the chest generally lasts for twenty-four hours in chil- dren and sometimes longer in adults, varying with their thresh- old of pain. Restlessness and pain are relieved by barbiturates, such as Nembutal and Luminal, and narcotics. When narcotics are used the nurse must be on guard against depressed respira- tions, especially when these are administered to a child. The requirement for constant nursing care is usually twenty- four to seventy-two hours, but varies with each patient. Careful consideration should be given the family during this immediate postoperative period. Allowing them to see the pa- tient as soon as the operation is over, and at least three times a day briefly, helps allay anxiety and apprehension. To permit them to see the patient, even if only for a five-minute period or less, gives them assurance that everything is being done for their loved one that is possible. Specical Considercations Cardiac Injuries. The care described under thoracic injuries on page 108 is applicable. In addition, preparation should be made for measurement of the venous pressure and for peri- cardial aspiration. The sterile articles essential for tapping the pericardium are: heart needles, 10 cc. Luer syringe, 50 cc. Luer syringe, rubber gloves, sponges and procaine, 9% per cent solu- tIOI). The patient's pulse should be felt frequently, with particular attention to the volume and regularity. An increase in the pressure within the pericardial sac causes the pulse to become more feeble. When there is a decrease in volume, the surgeon should be notified immediately. Chronic Constrictive Pericarditis. The patient is usually an adult who is admitted to surgery through the medical service where he has undergone treatment for the temporary relief of his ascites, dyspnea and edema. His pulse is feeble beſore operation and he complains of a feeling of general weakness. Following operation he is cared for like other patients with Cardiac surgery but with special attention to the volume of the pulse. It is convenient to have a venous pressure apparatus in SURGERY OF THE HEART AND GREAT VESSELS 189 readiness since the surgeon will measure it at intervals." The soft and undistended abdomen, the increase in pulse volume, and general increase in strength are the evidences of improvement which the nurse observes during convalescence. Ambulation depends entirely on the condition of the patient; sometimes it is begun on the third day, and sometimes not until the fourteenth day. Congenital Heart Disease Including Tetralogy of Fallof and Pure Pulmonic Stenosis. The cyanotic child or adult who comes for surgery has frequently been an invalid, leading an abnormal life physically and emotionally. The physical limitations have re- stricted his social contacts with others of his own age. The phys- ical problems manifested usually result in overprotection by par- ents or guardians. This produces dependency, immaturity and insecurity in the patient, regardless of age. While in some the mental development may be retarded, others may appear precocious. The child who has normal mental faculties often seems beyond his years in his mannerisms and speech because of continual association with well-educated adults. Because of the Constant Companionship and vigilance, the par- ents may seem oversolicitous, overanxious, and apprehensive. In reviewing the records of many of these children, one finds that it is not uncommon for the child and mother to have slept in the same room since the birth of the baby; a 4 or 5 year old child is still drinking from the bottle; and the diet is usually in- adequate. Behavior problems such as severe temper tantrums, kicking, spitting, biting, and other attention-getting devices, and immature response to situations are also common. The mother is usually aware of the diet and behavior problems but states that when she tried to correct them, the child became so agitated that she feared the child would die if she pursued them. Tantrums would bring on increased cyanosis, dyspnea and unwillingness to eat or drink. These she attempted to avoid and in so doing she “spoiled” the child. In view of the problems presented in each case, the nurse learns to understand the parents and child and in this way has a basis for beginning reeducation. The problems that such a pa- tient has must be dealt with gradually, and teaching includes both parent and child. A good time to begin is on admission. Taking the child and parents to the playroom where they may see 1 See Brown, pages 262-263. 190 NURSING IN VASCULAR SURGERY how well the other children can work and play together and ex- plaining the play program may serve as a start to establish rap- port and confidence. Iſ admission is at mealtime, it affords the parent the opportunity to see how well children eat together. When possible, the child should be allowed to eat with them, thus placing him in a normal routine. During the course of admission the nurse should avail herselſ of the opportunity to question the mother concerning habits of diet, sleep, elimination and play. Iſ he is partial to certain foods, arrangements should be made with the dietary department to try to obtain them. The mother should be questioned about his elim- ination and toilet training. Frequently the child has his own ex- pressions for the desire to void and deſecate and if the nurse is cognizant of these, there is a greater tendency to preserve and maintain good habits taught at home. The child learns the vo- cabulary of the hospital after a few days’ Companionship with other children so that this problem soon vanishes. Since most of these children have very poor teeth, good mouth care is espe- cially essential. If the dietary habits are extremely poor, and the behavior problems are intense then it is usually not advisable to try to change them before operation. To encourage the child to take adequate fluids, in the manner to which he is accustomed, is more important, preoperatively, than the fact that the child has not attained the proper behavior level for his age. The mother, in such cases, will also be less anxious and fearful if she is assured that the child will be cared for in the manner that she has de- scribed. Winning the confidence of the parents and the friend. ship of the child should be the goal of the nurse to insure an adequate basis for the care of such a child. The fluid intake and output is carefully measured and an ade- quate intake is maintained in order to prevent cerebral throm- bosis which may occur from dehydration and high polycythemia. Following operation, the pulse is taken in the arm opposite to the side of operation whenever the subclavian artery is used, as in the Blalock-Taussig technic, since no pulse can be felt on the affected side. The arm may feel slightly cooler, but no at- tempt should be made to warm it. The child usually resists movement of the arm on the side of operation. He should be encouraged to use the arm, exercising it by raising it, and by walking the wall with the fingers to help prevent deformity. SURGERY OF THE HEART AND GREAT VESSELS 191 Behavior reeducation and emotional readjustment cannot be fully accomplished during the patient's brief hospitalization but a start should be made. The usual hospital convalescence is from two to three weeks, depending on the condition of the patient. During this time there is often a great change in the personality of the child. He becomes more alert, takes an interest in other children, learns to take his turn, and learns that he is no longer the center of attention as he was at home and when first operated upon. As the appetite of the child improves an attempt should be made to teach him to eat a balanced diet. Eating with other chil- dren, having the nurse explain that a combination of all food helps to make him well, withholding dessert until he has eaten some of the food on his plate, serving food sieved, chopped or prepared to suit the child are methods which have proved effec- tive. The child who is still drinking from the bottle when over a year old, and who is physically capable of drinking from a Cup or glass, should be taught to do so as soon as his condition per- mits. Suggestions to meet this problem are: an attractive Cup, the use of drinking straws, encouraging him to eat and drink with the other children and as they do. The nurse should make use of her contacts with the parents throughout the child's stay. They should be informed of any training that is being done and of the progress made. Behavior problems mentioned earlier must also be met when present. Temper tantrums seldom appear following operation but when they do there are several ways to deal with the situa- tion. Ignoring the incident as much as possible, or if the behav- ior becomes intolerable to the group, isolating him where he can do no harm to himself or others usually curbs this tendency. Toilet training should be started as soon as possible by estab- lishing a definite time for toilet care. Commendation for good habits is also very helpful. Before the patient leaves the hospital, the parents are given definite instructions Concerning his activities. Activities of adult patients are restricted for one month; parents are advised to let their child find his own limit in exercise, which is usually the point when he becomes short of breath. He cannot enter into Competitive games. Whenever necessary, the doctor will refer the patient to a child guidance clinic convenient to his home. Not all children and parents need this service but, by and large, the 192 NURSING IN VASCULAR SURGERY child has a better chance to develop into an emotionally stable person when both parent and child understand what should and should not be done. Patent Ductus Arferiosus. The physical and emotional develop- ment of adult or child with this condition usually has not devi- ated far from normal. In general, he may appear a little more Trail and may have been somewhat overprotected because of his susceptibility to infections. Progress following surgery is rapid in uncomplicated cases. The patient may be out of bed the second or third day. In some clinics he is permitted to go home after a week; in others, he convalesces in the hospital from twelve to ſourteen days. The patient is instructed to increase his activity gradually and, after three months, all restrictions are removed. The doctor care- fully emphasizes the importance of prophylactic penicillin therapy if he has any minor surgery such as a tooth extraction, or if he contracts a respiratory infection. An inſection during the first six months may cause subacute bacterial endocarditis which, in turn, Could result in reopening of the ductus arteriosus. Coarctation of the Aorta. This healthy-appearing person usu- ally exhibits normal emotional stability. When an adult, the shoulders and trunk are large in Comparison to the somewhat underdeveloped lower half of the body. The child does not manifest any appreciable abnormality in physique. Following operation the blood pressure is taken in the arm and the leg and recorded accordingly. If there is a drop, it should be Called to the attention of the surgeon immediately, as this may mean a leak in the anastomosis of the aorta. After the second day, it is taken once daily for seven days. The adult male frequently has difficulty voiding for the first twenty-four to thirty-six hours. Urinary retention and discomfort should be reported. The patient is relieved either by a retention Catheter or repeated Catheterization until he is able to void. Complete bed rest for this patient is usually continued for twelve to fourteen days and he leaves the hospital about a week later. Physical activity instructions vary according to surgeons; some are more Conservative than others in permitting exercise. Very minimal activity for three months, gradually increased to normal within another three months, is satisfactory for many patients. Mitral Stenosis. The patient who has severe mitral stenosis is obviously ill. He develops fatigue and dyspnea with only slight SURGERY OF THE HEART AND GREAT VESSELS 193 exercise; he often has edema, especially of legs, ankles, and feet. He has been under the care of a physician for some time and has been referred to the surgeon to alleviate the increasing heart failure. The severity of the illness varies but fairly often such a patient has been incapacitated to such a degree that he is an in- valid on bed rest when he comes to operation. It is therefore im- portant to learn to know him by evaluating his way of life as manifested by his activities, his interests, his work and his re- strictions. Following operation, bed rest is continued for at least two weeks. Lethargy and fatigue are apparent. A quiet atmosphere, careful observations of the vital signs, and meticulous personal care should be provided not only while under constant observa- tion but also during the whole convalescent period. As the patient's strength increases, diversional therapy such as reading material supported on a book rack, or some hand work requiring very little activity, should be provided. A radio is also a helpful adjunct. Such a patient is carefully followed after discharge by both Surgeon and physician in order to determine the cardiac status and guide the patient's activities accordingly. SUMMARY Modern surgery has achieved its most brilliant success in ac- complishing by operative means the repair of cardiac injuries, of congenital defects of the heart and great vessels, and of abnor- malities resulting from disease. The technics are difficult and the nursing care of these patients demands special skill, patience, and Constant alertness. VOCABULARY REVIEW tamponade portacaval cardiac standstill Stenosis anastomosis polycythemia tetralogy of Fallot pericarditis valvulotome coarctation patent ductus angiocardiogram arteriosus SUGGESTED READING 1. Blalock, Alfred, and Ravitch, Mark: A Consideration of the Non-operative Treatment of Cardiac Tamponade Resulting from Wounds of the Heart. Surgery, 14:157–162 (August) 1942. 2. Blalock, Alfred, and Taussig, Helen B.: The Surgical Treatment of Mal- formationes of the Heart. J.A.M.A., 128:189–202 (May) 1945. 194 NURSING IN VASCULAR SURGERY 3. Gross, Robert: Surgical Management of the Patent Ductus Arteriosus. Ann. Surg., 110:321-356 (September) 1939. 4. Gross, Robert: Surgical Correction for Coarctation of the Aorta. Surgery, 18:673 (November) 1945. 5. Holman, Emile: Surgical Treatment of Tuberculosis Pericarditis. Arch. Surg., 61:266–272 (August) 1950. 6. McClure, Catherine T.: Guest in the House. Am. J. Nursing, 49:775–777 (December) 1949. 7. Potts, Willis J.: Tetralogy of Fallot. Am. J. Nursing. 47:298–300 (May) 1947. 8. Price, Constance Garside: Mitral Stenosis. Am. J. Nursing, 51:72–74 (Feb- ruary) 1951. 9. Stallman, Dorothy P.: Nursing Care in Cardiac Catheterization. Am. J. Nursing, 49:215 (April) 1949. Stevens, Marion: Visitors Are Welcome on the Pediatric Ward. Am. J. Nursing, 49:233 (April) 1949. 11. Wallace, Mildred: Care of the Child with Tetralogy of Fallot. Am. J. Nursing, 52:195–198 (February) 1952. 12. Wallace, Mildred, and Feinauer, Violet: Understanding a Sick Child's Be havior. Am. J. Nursing, 48:517-521 (August) 1948. I (). ) CHAPTER 18 Diseases of the Blood-forming Tissues and Spleen The commonest neoplastic lesion of the blood vessels is benign hemangioma (Chap. 4). This tumor is commonly found in the skin, but may occur in any part of the body; when symptoms arise from one of these they are usually the result of hemorrhage. Tumors of the cellular elements of the bone marrow (myeloma, leukemia) and those of the lymph nodes (lymphosarcoma) are not rare, however, and behave like malignant neoplasms. Hodg- kin's disease resembles these neoplasms of the blood-forming tissues in its malignant clinical course, but under the microscope the lesions are also suggestive of an inflammatory disease. The true nature of Hodgkin's disease is unknown. There is little to be done for these diseases surgically, other than biopsy to estab- lish the diagnosis. Radiation therapy has been beneficial for Some of the neoplasms of lymphoid origin, causing a regression DISEASES OF THE BLOOD-FORMING TISSUES AND SPLEEN 195 of the process, or in some instances even a cure. As a by-product of special investigation carried out during World War II, both radioactive phosphorus and nitrogen mustard have been found useful in the therapy of lymphoma and leukemia. The spleen is not a blood-forming organ in the adult: it serves instead as a filter, removing defective or worn out red blood cells from the circulation. In a certain group of diseases known as purpura the chief symptom is spontaneous hemorrhage. There is a defect of some sort in the blood, and in patients with Con- genitally defective red cells (hemolytic jaundice) the spleen filters out these red cells as fast as the bone marrow can make them. Since these unfortunate patients cannot form better red cells, and since the defective ones serve well enough to transport oxygen, these patients are improved by the removal of the spleen (splenectomy). Experience has shown that little improvement fol- lows splenectomy in most types of purpura, but in one form, as- sociated with a diminution in circulating blood platelets (throm- bocytopenia), splenectomy is often helpful. After operation, the number of platelets in the blood increases rapidly and the blood- clotting returns to normal. The spleen is often involved in tumors arising from the bone marrow or lymphoid tissue, but true tumors of the spleen itself are rare. In severe abdominal injuries, rupture or laceration of the spleen is common. Removal of the spleen is usually necessary to Control hemorrhage. Nursing Care Following Splenectomy. The careful preparation of the patient with a disease involving the spleen permits ample time for the nurse to learn to know him. This is in contrast to the patient who enters the emergency room following severe injury and who is admitted to the ward following splenectomy. The im- mediate preparation is similar to that for abdominal surgery. A Levin tube is usually inserted into the stomach before opera- tIOI). Following operation, the care depends upon the type of in- cision which may be either abdominal or thoraco-abdominal. When the spleen is removed by the latter approach, a chest catheter is usually in place. The principles of care are those de- scribed (p. 118) for chest surgery and for abdominal surgery (p. 233). The most frequent complications are atelectasis, hemorrhage, thrombosis, and infection. Careful observations of the vital signs are essential to allow early detection of any abnormality. Urging 196 NURSING IN VASCULAR SURGERY the patient to cough and breathe deeply helps prevent atelectasis. Antibiotics are ordered to prevent inſection. When hemorrhage occurs, it will be treated by the administration of blood; when thrombosis occurs, anticoagulants may be given. The time when the patient may be gotten up depends largely on his condition; the patient with splenectomy following injury usually gets up two or three days after surgery and may be ex- pected to make a more rapid recovery than patients who have had splenectomy for purpuric disease. SUGGESTED READING 1. Dunphy, J. E.: Splenectomy for Trauma, Practical Points in Surgical Technic. Am. J. Surg., 71:450–460 (April) 1946. 2. Giannini, Albert P.: Splenectomy for Essential Thrombocytopenic Purpura. Surg., Gynec. & Obst., 94:229–236 (February) 1952. 3. Lahey, Frank H., and Norcross, J. W.; Splenectomy, When Is It Indicated: Ann. Surg., 128:363-377 (September) 1948. 4. Proudfit, Fairfax T., and Robinson, Corinne Hogden: Nutrition and Die Therapy. 10th Ed. New York, The Macmillan Co., 1951, pp. 295-305. Unit IV. NURSING IN SURGERY OF THE ALIMENTARY TRACT CHAPTER 19 Introduction Anatomy and Physiology. It will be helpful to the student to think of the alimentary tract as a long tube extending from the mouth to the anus. It serves primarily to convert into the chemi- cals needed by the living cells of the body that portion of the food eaten which is suitable and to excrete that portion which cannot be utilized. In some of the more primitive forms of ani- mal life the alimentary tract is indeed a simple, straight tube; but in the human being the tract is many times longer than the body, there are considerable differences in the structure and function of its various portions, and a number of important large glands are derived from it. Throughout its entire length the tube is lined by epithelial cells, and the wall of the tube is muscular. Mouth and Esophagus. The entrance to the uppermost portion of the alimentary tract, the mouth (oral cavity), is guarded by the lips. Within the mouth are the tongue and the teeth, and into 197 198 NURSING IN SURGERY OF THE ALIMENTARY TRACT Mouth (Oral covity) Esophoqus Stornach Pylorus (Pylonic sphinctor Lorge intestine Largº intestino (Colon) Small into sting Verrniform Sphinctor on AppendixTV | Anus FIGURE 64. The alimentary tract. the mouth empty the ducts leading from the paired saliva-pro- ducing glands (parotid and submaxillary glands). The back of the mouth opens into the esophagus; this relatively straight Com- ponent of the tract runs down the neck immediately behind the trachea and similarly extends through the thoracic cavity, lying on the bodies of the thoracic vertebrae; it finally passes through the diaphragm, and empties into the stomach. Stomach. The stomach and all of the remaining portions of the tract, except the anus, are situated within the abdominal cavity. Located anteriorly beneath the dome of the left dia- phragm, the stomach is an easily distended, baglike structure, open at both ends. The wall of the stomach is thickly muscled, and at the distal opening (pylorus) there is an especially strong INTRODUCTION 199 ring of muscle fibers (pyloric sphincter) that controls the empty- ing of the stomach. Small Intestine. The next portion of the tract is the small in- testine. This tortuous tube is by far the longest part, and is di- vided into three sections: the duodenum, jejunum, and ileum. Bile from the liver and the digestive ferments from the pancreas are poured into the duodenum. The terminal portion of the ileum empties into the cecum, which is the first section of the large intestine (colon). To the cecum is attached the wormlike (vermiform) appendix. Large Intestine. The large intestine is composed of the cecum and ascending right colon, the transverse colon, the descending left colon, the sigmoid colon, and the rectum. The outlet of the tract is the external orifice (anus) located in the middle of the perineum; it is guarded by a strong ring of muscle (sphincter ani) that keeps the anus closed except during the expulsion of feces or flatus. It is obvious that the largest part of the alimentary tract lies within the abdominal cavity, and therefore most of the surgery of this tract is abdominal surgery. Infection. The food we eat, the utensils we place in our mouths, while usually clean, are seldom sterile. It is, therefore, essential in all surgery of the alimentary tract to realize that every part of the tract may and usually does contain bacteria, many of them pathogenic. The continuous sheet of epithelial cells forming the lining membrane (mucosa) of the tract affords the same pro- tection from these bacteria as does the epithelium of the skin, but it must be remembered that any break in continuity, whether accidental or surgical, can serve as a portal of entry for bacterial invasion (Chap. 3). CHAPTER 20 Nursing in Oral Surgery CLEFTS OF LIP AND PALATE Cleſt palate and cleft lip (harelip) result from a failure of the developing lateral portions of the face and mouth in the fetus to unite in the midline as they do normally. These defects occur alone or in combination, and there is considerable variation in the degree of deſormity of the upper lip, nostrils, alveolar process (upper jaw), and palate. The cleft is said to be complete when there is direct communication between the cavities of the nose and mouth and the exterior. Obviously, this deformity interferes with the nutrition of the infant, since nursing and bottle feeding are impossible. If such deſormity is not corrected, moreover, a characteristic speech disturbance will be present in addition to the unſortunate appearance of the child. Treatment. The cure of cleft lip and palate can be accom- plished by surgical measures, and in favorable cases correctly treated there is perfect function and the operative scar can scarcely be detected. The operation for harelip should be under taken within the first ſew weeks of life. Successful early operation improves the infant's ability to ſeed and enables the mother to exhibit the child without distress. Even more important, when a combined defect is present, is the pull exerted by the closed lip upon the cleft palate which approximates the separated alveolar processes and thus Creates more favorable conditions for closure. These advantages far outweigh the hazard of operating upon a very young inſant and the difficulty encountered in dealing with its miniature anatomy. After repair of the lip, closure of the cleft palate may be deferred until the child is 18 months old. Repair of harelip demands both knowledge and skill, for success depends upon the accurate recognition of the misplaced por- tion of the vermilion border, skin, and lip muscle and the utiliza tion of all available tissue. The opposing portions of the ver milion border must be approximated exactly to prevent notching of the lip margin. In this work infection is disastrous, for not only does the repair break down, but much-needed tissue is lost 200 t NURSING IN ORAL SURGERY 201 FIGURE 65. Harelip and cleft palate. and the hope of success in a future attempt is lessened. Penicillin is administered until healing is complete. The best procedure for closing a cleft palate is a plastic opera- tion which utilizes relaxation incisions in the mucous membrane of the roof of the mouth. Small flaps of the membrane are ele- wated and are shifted so as to come together over the cleft with- out tension, thus closing it. Nursing Care. Good nursing is essential; the repair may be skillfully performed and the result may be impaired by poor nursing care. The patient is always photographed before opera- tion. He is given the preparation which is routine for patients who are to have a general anesthesia. The regular postoperative unit is prepared. In addition, suc- tion, sandbags and restraints should be at hand. Sandbags are placed on either side of the patient's head to prevent him from rolling on the suture line. In the case of a baby, elbow restraints should be used Con- stantly until the suture line is completely healed and the sutures have been removed. Wrist and ankle restraints may be used for older children depending on their age, cooperation, and advice of the surgeon. A free airway should be maintained. The most frequent ob- struction in this type of case is caused by suction of the lower lip against the upper. This may be remedied by traction downward of the lower lip with a bit of adhesive tape. The prevention of strain on the suture line seems to be most difficult in babies. Sedation should be given to prevent crying, especially during the first forty-eight hours when the food intake may not be sufficient to prevent hunger. When this does not suffice, picking the infant up, walking with him, or rocking him may prevent Crying. The older child also demands much attention, especially dur- 202 NURSING IN SURGERY OF THE ALIMENTARY TRACT ing the postoperative days. Many of them are very understand. ing and will not disturb the suture line but others pick at the suture line and cry, remaining quiet only when the nurse holds them or amuses them. After the first day, the child will usually take part in directed play activity. Infants should be fed by a medicine dropper fitted with a rub. ber tip, the dropper directed along the cheek away from the affected side. If the repair is bilateral, the dropper should be introduced centrally or along one side of the mouth at the point of least strain. The formula should be fed drop by drop to pre- vent regurgitation of the feeding through the nose. Milk forms a crust or film on the suture line and 5 cc. of sterile water should be given by dropper after meals to clean the mouth. In some clinics, sterile diet is ordered for all patients with repair, but in others, clean dishes and food are considered adequate. The baby should be bubbled while held in the nurse's lap rather than by the more usual over-the-shoulder method, in order to prevent trauma to the repaired lip. A nipple should not be used for ſeed. ing until the suture line is completely healed because the sucking action may be sufficiently forceful to break down the suture line. The older child may be fed with a sterile, rubber-tipped Chet. wood syringe or, using a sterile medicine glass the liquids are poured, a little at a time, into the mouth. Sucking must be guarded against. The surgeon leaves definite orders for the care of the lip. It is sometimes ordered that the suture line be kept clean of crusts and serum by wiping with toothpick swabs wet with hydrogen peroxide every half hour for the first twenty-four hours after operation and moistened with sterile oil every four hours. When no Orders are left to cleanse the suture line, then the under lip and tongue should be kept in a moist condition by applying sterile white oil after cleansing with toothpick swabs dipped in sterile water or aqueous Zephiran. Some surgeons use the Logan bow to take tension off the suture line. This is attached by adhesive tape. If the tape becomes loose, the surgeon should be notified immediately so that new tape may be applied. Before discharge, when the patient is an infant, the mother should be asked to come to the hospital to feed the child several times under the supervision of the nurse. The mother is naturally anxious about feeding the baby and can be put at ease by proper instruction in the procedure to be followed. Older children will NURSING IN ORAL SURGERY 203 be able to eat a soft diet satisfactorily. The nurse should be sure that the parents know when they are to return to the surgeon. Most surgeons want a photograph made of the patient just before discharge. After-Care. Speech training is usually necessary to prevent the otherwise inevitable nasal tone. Since the child learns to talk by imitation it is important that those associated with him under- stand that correct enunciation is the basis of good speech train- ing. There should be a regular weekly practice period of one half to one hour, depending upon the age of the child. Simple words which have consonants that are defective in the child's speech should be practiced. Direct attention should not be called to de- fective speech at other times. There is danger that the child may become sensitive, frustrated and unhappy if he feels that he is being “pushed.” Proper phonation will be acquired with patient and tactful teaching. It has been found invaluable to organize a speech clinic so that a regular teaching program can be con- ducted by trained workers. TONGUE-TIE This common deformity results from undue forward prolonga- tion of the frenum, a fold of mucous membrane Connecting the base of the tongue to the floor of the mouth. Causing a consider- able speech deſect, tongue-tie is easily cured by snipping the mem- brane with a scissors. Care must be taken to avoid the large blood vessels which lie beneath the tongue. INFECTIONS OF THE MOUTH In addition to its effective defense against bacterial invasion, the mucous membrane of the mouth possesses remarkable power of repair. Thus not only do tiny abrasions and scratches incident to the wear and tear of ordinary eating heal rapidly, but also accidental and surgical wounds heal quickly even in the face of Constant bacterial contamination. It seems likely that tissues which are continually exposed to bacteria develop an increased local resistance. The deeper tissues about the mouth, however, do not possess such qualities, and are susceptible to infection. Moreover, this region is rich in lymphatics, and the inflammatory process soon spreads to the many lymph nodes beneath the floor of the mouth and in the neck. Cervical lymphadenitis is thus a common complication of all oral infections. 204 NURSING IN SURGERY OF THE ALIMENTARY TRACT Stomatitis. Damaged or neglected teeth are the commonest source of infection of the tissues about the mouth. Continued lack of dental hygiene, with consequent irritation and inflamma- tion of the mucosa of the gums by the accumulation of decaying food, prepares the way for invasion of the alveolar tissues. A very acute ulcerative inflammation of the mouth (stomatitis), known also as trench mouth and Vincent's angina, often develops in such a neglected mouth. The causative microbe of this disease is a spirochete. The mouth and gums are ulcerated and painful, and the inſectious process may spread to the deeper tissues, some times with very serious consequences. If treated early and vigor. ously, however, the stomatitis clears up promptly. Correct treat- ment includes regular frequent cleansing of the teeth and massag. ing of the gums with sodium perborate. In severe cases it may be necessary to use penicillin, administered just as in the treatment of syphilis. Infection of the Deeper Tissues. Bacteria Commonly enter the deeper tissues through a broken tooth, or through one that is decayed (carious) or devitalized. Toothache is the first warning: later, the gum becomes painful and swollen. A gumboil (alveolar abscess) may form; this may rupture spontaneously or may be drained by surgical incision. In other instances, however, the inflammatory process spreads to involve the jaw (mandible) and adjoining tissues. Such a patient has severe, throbbing pain in the whole side of the mouth and face, and there is swelling of the involved jaw, extending to the cheek and neck, with inability to open the mouth freely (trismus). The degree of bone inſection (Osteomyelitis) varies; suppuration often occurs, and both cervical lymphadenitis and cellulitis of the tissues of the floor of the mouth (Ludwig's angina) are frequent complications. Treatment. The best treatment of infections of dental origin is prevention. This means regular visits to a competent dentist in addition to proper hygiene in the home. GENERAL MEASURES. Treatment must include rest in bed, seda- tives, a mildly antiseptic mouthwash, and antibiotic therapy. Some surgeons prefer the local application of heat, while others prefer cold. In the acute stage of the disease no attempt to extract the affected tooth should be made, for the trauma incident to extraction would open up new avenues of spread for the invad- ing bacteria and would, by devitalizing additional tissue, reduce the local resistance to bacterial growth. INCISION AND DRAINAGE. Sometimes the acute inflammatory NURSING IN ORAL SURGERY 205 process subsides without suppuration; when this occurs it is the signal to treat the original cause of the infection, otherwise there will soon be a recurrence of the trouble. In other instances the acute cellulitis is followed by pus formation, indicated usually by a softening of the central portion of the indurated tissues or by frank fluctuation. Surgical incision and drainage are then in- dicated, and the necessary incisions are located with careful atten- tion to such considerations as providing ſree and dependent drainage without interference to blood supply, without injury to nerves or other important structures, and at the same time mini- mizing facial disfigurement. Warm antiseptic mouthwashes should be administered at least every two hours during the pa- tient's waking hours, until swelling subsides. The patient should be encouraged to expectorate the pus. A sputum Cup should be kept at the bedside. In many cases, free and early surgical drainage suffices to cure osteomyelitis of the mandible, but at times it is necessary to remove small portions of necrotic bone. Cellulitis; Mediastinitis. Acute infections of dental Origin usu- ally spread to the upper cervical lymph nodes on the affected side, but occasionally the process extends medially, involving the tissues of the floor of the mouth. Cellulitis in this region is at- tended by great swelling and induration, and since these tissues are beneath a covering of dense fascia there is likely to be com- pression of the structures within the upper neck. Difficulty in Swallowing (dysphagia) and respiratory obstruction may occur. At the same time the infectious process may extend rapidly down- ward beneath the deep cervical fascia. Inflammation of the tissues of the mediastinum (mediastinitis), a highly ſatal Complication, may thus follow failure to recognize and properly treat cellulitis of the floor of the mouth. Treatment. Formerly it was considered best to treat cellulitis of the floor of the mouth (Ludwig's angina) conservatively, but surgeons now realize the importance of early incision with di- vision of the deep cervical fascia, thus at one stroke both relieving the compression of the deep structures of the neck and, by pro- viding free access to the exterior, lessening the likelihood of ex- tension of the infection down the neck into the mediastinum. Even so, there is sometimes so much edema of the inflamed tissues that respiratory obstruction occurs. A rapid increase in Swelling, noisy respirations, and cyanosis are signs of repiratory obstruction. An emergency tracheotomy may be required, and the necessary instruments, therefore, must always be available 206 NURSING IN SURGERY OF THE ALIMENTARY TRACT and in condition for immediate use. Antibiotic therapy is, of course, begun at once. SALIVARY GLAND DISTURBANCES There are four salivary glands; one of these is situated imme- diately in front of and below each ear (parotid glands), and One is located on each side of the midline just beneath the floor of the mouth (submaxillary glands). The parotid duct on either side pierces the muscles of the cheek aſter leaving the gland; the open- ing into the mouth is lateral to the upper first molar tooth. The branches of the facial nerve, essential to the function of the facial muscles, pass beneath or through the parotid gland, an anatomic fact of great consequence to the surgeon. The submaxillary ducts open into the floor of the mouth close to the midline, on either side of the frenum of the tongue. These four openings are large enough to be seen with the naked eye, although the ducts are quite small. During the act of chewing (mastication) saliva flows out freely, at other times more slowly. Stones. Small stones (concretions) occasionally form in any ol these ducts, perhaps more commonly in the submaxillary ducts because of their more dependent position. Concretions are also formed within the much smaller tributary ducts which lie within the glands themselves. A salivary concretion is symptomless until it is of sufficient size to obstruct the duct in which it lies. When obstruction occurs the characteristic symptoms are pain, tender- ness, and swelling of the affected gland, all rendered more severe during the act of eating. Examination shows a tender, swollen gland, with no discharge of saliva from its duct. Most of these stones contain calcium and, even though tiny, can be demon- Strated by roentgenography. Treatment. Small as they are, salivary stones are troublesome to treat. In favorable cases the stone may be dislodged by probing or by Surgical exploration of the duct. In other instances acute inſection may be present, necessitating different therapy; finally, it is oſten necessary to remove the affected gland in order to relieve the patient permanently. Inflammation. Acute inflammation of the parotid gland is not uncommon, and is differentiated with some difficulty from mumps (acute epidemic parotitis). In the ſormer, however, there Is either an absence of secretion from the duct, or there is a purulent secretion. The symptoms are much the same as in ob- struction without infection, but are usually more severe, with NURSING IN ORAL SURGERY 207 ſever and other systemic symptoms added. Acute parotitis is sometimes a terminal complication in patients who are much debilitated by other disease, and is probably due to drying of the oral mucous membrane with Consequent lowering of its resistance to bacterial Invasion. Treatment. The proper treatment for acute parotitis consists in general measures such as rest in bed, increased fluid intake, and the administration of sedatives. Antibiotic therapy is given. Local treatment includes hot or cold applications depending on the surgeon's preference; some authorities advocate x-ray therapy. Iſ actual suppuration occurs, Surgical incision and drainage are required. A mouthwash and other measures to promote oral cleanliness are essential. Acute inflammation of the Submaxillary glands also occurs, but is less Common than acute parotitis; there Is no difference in the treatment of the two. Neoplasms. Both benign and malignant tumors occur in the salivary glands, more often in the parotid than in the sub- maxillary glands. Parotid tumors are usually slow in growth and readily curable by excision iſ treated early. Occasionally the facial nerve must be sacrificed. TUMCRS OF THE MOUTH, TONGUE AND JAW The oral cavity is a common site of neoplastic disease. The fre- quency of injury to the mucous membrane, the Constant presence of bacteria, and the conditions arising from the growth and main- tenance of the teeth are undoubtedly contributing factors. The use of tobacco may also be a possible factor. Cancers arising from the lup, tongue, and oral mucous mem- brane grow more rapidly than similar tumors of the skin, and metastasis to the neighboring lymph nodes in the neck occurs relatively early. Cure is therefore less likely, and is made even less satisfactory because of the mutilation which is caused by extensive resection of the lips, tongue, or mouth. The relative merits of the surgical removal of these tumors and their treat- ment by roentgen-ray or radium will not be discussed here; many patients have been cured by excision and/or radiation. The presence of a small, persistent ulcer, usually but not always pain- less, constitutes the signal for immediate diagnosis and treatment while there is still a chance for cure. The tumors which arise from bone elsewhere occur in the jaws (mandible and maxilla) as well. In addition, there are certain other neoplasms found in the jaws and not elsewhere which are 208 NURSING IN SURGERY OF THE ALIMENTARY TRACT 6. N & #ºfº) #&@ mºjiº, sº 'ſſ Nº º º) $º) | "(Nº. º) \ \º º sº * * FIGURE 66. Cancer of the lip. The dotted line outlines the portion of lip which must be excised. due to the presence of tooth-forming tissues. Dental root cysts and tooth-bearing (dentigerous) cysts are benign growths, cured by local removal. The adamantinoma, however, is a malignant neoplasm arising from the epithelial cells of the adamantine glands (enamel-forming glands), and is cured only by complete resection. The diagnosis is suggested by swelling of the jaw, with or without pain; x-ray examination usually shows a character- istic picture, but biopsy may be necessary. Dental infection and osteomyelitis of the jaw must be distinguished from neoplastic disease. The term epulis refers to any tumor arising from the gums, but is usually applied to a tumor of connective tissue origin which is characterized by large, multinucleated giant cells. It is a benign lesion. Retention cysts of the mucous glands are not uncommon, and an occasional large cyst forms from an obstructed duct located in the floor of the mouth beneath the tongue (ranula). These are cured by excision. Nursing Care. The extensive operative procedures often needed in the treatment of cancer of the oral cavity are the source of much discomfort and disability. The same may be said with respect to the widespread destruction of tissues occurring in ad- vanced inoperable cancer. The important features of the nurs. ing care of such patients are procedures designed to increase the patient's comfort and to aid healing. On admission, the surgeon usually orders antibiotics, vitamins NURSING IN ORAL SURGERY 209 and a high caloric diet in preparation for operation. The patient is photographed, necessary x-rays are taken and, when the sur- geon anticipates the need for a prosthetic appliance, a mold is made. This will help restore maximum function and normal ap- pearance. Infected teeth may have to be extracted before the major operation is performed. The usual immediate preopera- tive preparation for general anesthesia is given. Oral hygiene is especially essential. In addition to the usual postoperative unit, suction should be available. Equipment necessary for tracheotomy care (p. 500) should be provided when a tracheotomy is to be done. Suction catheters should have only one hole and this should be in the end. Following operation, the unconscious patient is placed in bed on his abdomen with his head turned face down, or on the side opposite operation. Sometimes the surgeon prefers to place the patient in bed with the head elevated in order to reduce venous pressure. Before the nurse assumes the responsibility for the care of the patient, she should understand what has been done at operation and, iſ packs were inserted, she should know their location and points of attachment. She should also know whether the trache- Otomy is temporary or permanent. The nursing responsibilities immediately following surgery include: keeping the airway open, observing the patient's Color, taking the blood pressure, temperature, and pulse, Counting the respirations, and administering fluids and medications as ordered, including antibiotics. The dressings applied to the neck and face of the patient usually consist of huge amounts of mechanics' waste held in place by tight bandages. This pressure dressing obliterates dead space and aids healing by preventing edema, supporting ven- ous return, and splinting the part. When the patient has an endotracheal tube in place, the lumen must be kept open by the use of suction with a catheter inserted into and through the entire length of the tube to insure the removal of secretions. Suction should be used as often as there is audible congestion. Coughing is encouraged and, when ordered, is stimulated by passing the catheter down into the trachea. The mouth should be emptied by suction of saliva and blood because the patient will be unable to expectorate and swallowing may be difficult for several days. The endotracheal tube is removed by the surgeon 210 NURSING IN SURGERY OF THE ALIMENTARY TRACT or anesthetist when there is no longer danger of tracheal Ob- struction, usually after the patient is conscious. Respiratory embarrassment or obstruction may be caused by packs, by the collection of excessive secretions or by bleeding. When there is a tracheotomy, care should be taken to prevent obstruction of the airway by the careless placing of blankets and sheets. By removing the packs or clots, and by sucking away the secretions, relieſ is immediately obtained. When the patient has a tracheotomy, care is given in the manner described on page 500. Pain is controlled by the use of narcotics which should be given cautiously because these agents depress respirations and the cough reflex. If the surgeon has ordered a narcotic to be given whenever necessary, the nurse should watch the depth and rate of the respirations before giving the drug. Respirations should always be above 14 per minute when a narcotic is administered unless the surgeon orders otherwise. If the patient is restless, it may be an early sign of respiratory obstruction rather than an indication of pain. After operation the patient is fed a high caloric, high protein, fluid mixture through a Levin tube passed through the nose into the lower esophagus. Actual swallowing is not encouraged at first because of intraoral sutures, packs and/or skin grafts. As soon as sufficient time for healing has elapsed, swallowing is encouraged. The Levin tube is left in place because at first the patient will be unable to drink enough fluids to meet the daily ſood requirements. Milk and orange juice are avoided when there are packs in the mouth because of the tendency to ferment. Swal- lowing is difficult because of the anesthesia of the operative site and the loss of muscle power. The patient will be frightened in his first attempts to swallow because the fluids may run down his larynx and be expectorated through his tracheotomy tube. The nurse should understand this so that she can patiently re- assure and encourage him to keep trying to swallow. Coughing from such efforts is exhausting; too much insistence on trying will tire the patient. Swallowing should be learned gradually and only water is used until the patient learns to protect his trachea. Usually by the fifth to the ninth postoperative day the Levin tube may be removed. The tube is a continual source of annoy- ance to the patient and the removal at the earliest feasible time will make him more Comfortable and assure him that his progress is satisfactory. NURSING IN ORAL SURGERY 211 Talking is usually possible but very difficult. The patient should be encouraged to communicate by writing. A large num- ber of sheets of paper and a pencil attached to a chart back should be given him; a pad covered with plastic, from which the writing is erased by lifting the plastic material, is excellent for this purpose. A scratch pad and pencil suffice but the patient will write more freely and with less restraint when a larger amount of paper is provided. Teaching the patient self-care by explaining his care as soon as possible (usually the second postoperative day) is advisable. Encouraging him during subsequent days is important to build up his morale. Early teaching gives the patient more security and at this time there is greater willingness to learn. The nurse must safeguard him from feeling pushed; his activity in learning should proceed according to his adaptations. Care must be taken in this area lest the patient learn self-care to win approval. During convalescence there is often an apparent depression of spirits. Talking to the patient, encouraging him to communi- cate, Caring for him gently, patiently, tactfully and sympa- thetically give him security and help lessen mental distress. The dressings are usually removed on the fifth or sixth day, at which time sutures are partially removed and the drain is shortened. Usually after the first or second dressing the patient will use a mirror to see himself. The patient will know what to expect and will be able to accept this according to his prepara- tion for this by the surgeon and his adaptation to living before operation. The nurse should be alert to relay the patient's reaction. She should encourage him to withdraw his attention from himself by thoughtfully making him associate with other ambulatory patients and engage in diversional therapy of some SOrt. Such a patient may be discharged from the hospital after two to three weeks. Explanations of the return visits to the surgeon should be clearly defined and a written appointment slip pro- vided. Every effort to instruct the patient's relatives during con- valescence will prepare them for his return home; iſ they have been inſormed throughout his stay, they will understand his care. Dietary care should be planned during convalescence to provide for it adequately. When a laryngectomy has been carried out, the speech ther- apist usually is able to begin his instruction of esophageal speech four to six weeks after operation. When a prosthetic device is 212 NURSING IN SURGERY OF THE ALIMENTARY TRACT recommended, it is usually made after the patient is discharged and may not be worn until Complete healing has taken place. SUMMARY The common lesion of the oral cavity in infancy is harelip with cleft palate. Infections occur in young and old. Cancer takes its toll of the middle-aged and older individuals. The nursing care following surgery about the oral cavity is particularly concerned with assistance in breathing, swallowing, and speaking; in addi- tion, these patients have a hard adjustment to make to the mutilation which may result. VOCABULARY REVIEW harelip Ludwig's angina epulis stomatitis mandible tracheotomy parotid maxilla ranula trismus SUGGESTED READING 1. Cooper, Lenna, Barber, Edith M., and Mitchell, Helen S.: Nutrition in Health and Disease. 11th Ed. Philadelphia, J. B. Lippincott Co., 1950, p. 389, 2. Martin, Hayes: Cancer of the Head and Neck. J.A.M.A. 137:1366–1376 (August 14) 1948 3. Ward, Grant E., and Hendrick, James W.; Tumors of the Head and Neck. Baltimore, Williams & Wilkins Co., 1951. 4. Ward, Grant E., and Robben, J. O.: A Composite Operation for Radical Neck Dissection and Removal of Cancer of the Mouth. Cancer, 4:98–109 (January) 1951. . Welborn, Joseph F., and Waters, Mary H.; Nursing Care for the Patient Having Oral Surgery. Am. J. Nursing, 51:74–77 (February) 1951. 6. Post, Grace C., and Mason, Katherine N.: Nursing Care in Cleft Lip Repair. Am. J. Nursing, 48:768–770 (Dec) 1948. 5 CHAPTER 21 Nursing in Surgery of the Esophagus Until quite recent times surgical treatment of esophageal lesions was both uncommon and not often successful. There are many reasons for this. Bacteria of all sort may be found in the esopha- gus. The wall of this portion of the alimentary tract is composed of smooth muscle fibers which form, it is true, a thick Coat, but it is well known that muscle neither holds sutures nor heals well; this organ has no strong, fibrous sheath like the submucosa of the remainder of the tract, nor is the external Surface Covered with a serous coat like the peritoneum which adheres and heals so quickly. Then, too, although the cervical portion of the esopha- gus is readily accessible, the largest part of this tube lies within the thorax; surgical approach to it was not safe before the recent extensive developments in the field of thoracic surgery. It is also a fact that lesions of the esophagus, except those of an accidental or traumatic origin, do not produce symptoms early; the esopha- gus is a remarkably silent organ, and, notwithstanding the constant use that is made of it, regurgitation of food is the chief symptom of esophageal disease, and is caused only by some form of obstruction. Regurgitation must be carefully distinguished from vomiting. The latter is the more or less ſorceſul discharge of the contents of the stomach, whereas regurgitation is not forceful, and the ma- terial so returned to the mouth is in the same state as it was upon being swallowed, since it has not been exposed to the digestive action of the gastric juice. Chewed but undigested food is easily recognized, and no gastric juice is present. WOUNDS OF THE ESOPHAGUS The esophagus, because of its well-protected position, is not often injured. It may, however, be penetrated in gunshot and stab wounds of the neck, and is occasionally lacerated in a sui- cidal or homicidal throat-cutting. Such wounds of the esophagus show a remarkable tendency to heal spontaneously. It is im- 213 214 NURSING IN SURGERY OF THE ALIMENTARY TRACT portant to keep the neck wound open widely so that healing will take place [rom the bottom upward, because any wound that communicates with the lumen of the esophagus is Certain to be an infected wound, and iſ the wound does not have free ex- ternal drainage the infectious process may extend down the neck into the mediastinum. Healing is further aided by feeding the patient through a soft rubber tube that is passed through the mouth into the stomach, and by urging him to expectorate rather than swallow his saliva. In this way the wound is kept cleaner and dryer. An intrathoracic wound of the esophagus uncomplicated by a fatal wound of the heart or great vessels is rare, so closely together do these structures lie in the mediastinum. BENIGN ESOPHAGEAL STRICTURE It seems incredible, yet it is a fact, that in many American homes today there is under the kitchen sink, or elsewhere within the reach of some curious but unsuspecting child, an easily opened container of lye, one of the most caustic of all poisons. One mouthful is enough to disillusion the unfortunate child, but it is also enough to cause severe burns of the mouth and esophagus. Burns caused by lye usually heal readily without much treat- ment of any sort, but in healing scar tissue is produced. Scar tissue tends to contract: thus if the esophageal burn has been circum- ferential in nature, a circular Constriction of the esophagus is the end-result. Treatment. If the patient receives adequate care soon after the burn is incurred, much can be done to prevent serious con- striction. By passing bougies frequently during the healing period and thereafter, the esophagus can be kept open so that a lumen of useful size remains. If, however, this aspect of the treat- ment is neglected, symptoms of progressive obstruction will appear in a few weeks. An occasional patient does not come under proper care until actual starvation and dehydration occur. Gastrostomy. In treating patients who have already developed esophageal obstruction to a degree that renders adequate fluid and food intake difficult or impossible, the first step is to provide some other route by which the patient's nutrition can be main tained. This is done by an operation in which the surgeon creates an artificial opening into the stomach through the abdominal wall (gastrostomy). This procedure can be carried out undel local anesthesia upon even the most debilitated of patients. NURSING IN SURGERY OF THE ESOPHAGUS 215 Determination of Patency. As soon as the patient's condition permits, examination of the esophagus is undertaken to deter- mine the course of further treatment. Three methods are avail- able, all of which are useful. The lumen of the esophagus may be Inspected directly by means of the esophagoscope, an electrically illuminated tube almost exactly like the bronchoscope. It is usu- ally impossible to pass the instrument below the constriction, but the examiner may at least view the upper margin of the Con- tricted portion of the esophagus, and may determine with accuracy the nature of the lesion causing the obstruction. The remainder of the esophagus may be explored by means of soft rubber bougies of different sizes, but even better is the visualiza- tion of the lumen by means of fluoroscopy during the Swallowing of Small amounts of barium. If the lumen is at all patent, attempts are made to enlarge it. This is sometimes possible through the use of bougies; another method is to have the patient swallow one end of a string. This end is later recovered from the stomach through the gastrostomy by carefully fishing it out with a blunt hooked instrument. Both ends of the string are then secured, and beads of graduated sizes are attached and are carefully drawn through the constricted esophagus until, aſter many months, the desired lumen is present. During this period, all or most of the patient's fluids and food intake must be supplied through the gastrostomy; full details of this are given in the section on surgery of the stomach. Reconstructive Surgery. Very occasionally there is complete closure (stenosis) of the esophagus following a lye burn. For even such an unfortunate individual there is hope. Cases have been recorded in which there has been successful, complete construc- tion of a new esophagus, thus rehabilitating victims otherwise restricted for the remainder of their lives to feeding by gas- trostomy. Nursing Care. The resultant stricture of the esophagus of the child or adult may be the same, but the manner in which the accident occurred may differ greatly. While lye is the usual causa- tive agent in the child, any caustic, even hair dye, may be taken by the adult. The child was curious when he tasted the lye, but the adult usually got his burn from attempting suicide. Evalua- tion of the socio-economic and emotional status of either is im- portant and guidance in care should be sought. Preparation for treatment with bougie consists of witholding fluids for six hours. Since the surgeon usually anesthetizes the 216 NURSING IN SURGERY OF THE ALIMENTARY TRACT throat, the patient could easily aspirate vomitus unless his stomach is empty. It is also necessary to permit no fluids follow- ing the procedure to prevent such a complication. The immediate preoperative and postoperative care of the patient with a gastrostomy is like that for routine surgery. In- travenous ſluids are given before, if necessary, and afterward to maintain fluid balance. After twelve to twenty-four hours, the surgeon usually orders liquids to be given directly into the stomach through the gastrostomy tube. At first, water is usually alternated with 200 cc. of tube feeding (p. 50) every two hours, but later, when there is no longer danger of nausea, tube feeding is given every two to four hours depending on the amount the patient is able to take without discomfort. Some patients Com- plain when more than 200 cc. of fluid is placed in the stomach. Such patients require frequent feedings to insure both adequate fluids and nutrition. Water must be given the patient in addition to the feeding to supply him with the 3000 cc. necessary daily requirement. The adult should be taught within the first few days after gas- trostomy to feed himself. Attaching an Asepto Syringe and in- troducing the feeding before releasing the clamp on the tube prevents air from entering the stomach. Water should always be added, following tube feeding, to wash down the mixture. The Asepto syringe should not be removed until the clamp has been reapplied, thus preventing back flow. Occasionally the surgeon advises patients to utilize a regular diet. The patient is taught to chew the food, and then expec. torate it into a funnel which is attached to the end of the gas- trostomy tube. This allows for mixture with the salivary juices and also helps preserve the teeth. If this is done in the hospital, the nurse must insure the privacy of the patient; other patients on the ward should not be subjected to this unesthetic manner of eating. Whether the patient takes tube feeding or a regular diet, it is the nurse's responsibility to see that he knows the contents of each. In addition, he should know the amount of water that he is to take daily. Once healing has occurred and the tissues are no longer tight about the tube, an unavoidable complication of gastrostomy is the leakage of small amounts of gastric Contents out onto the abdominal wall. This is disagreeable in two ways, for not only does the material have the unpleasant odor of vomitus but also it is wet and irritating to the skin. Successful placing and con- NURSING IN SURGERY OF THE ESOPHAGUS 217 struction of the opening reduce leakage to a minimum, but do not completely obviate it. If the patient can lie down after meals until the stomach is nearly empty, the leakage is less. The use of soft and absorbent material for a dressing around the opening is very helpful; frequent change of dressing is advisable. A sanitary napkin cut half way through its length can be fitted around the tube and is a suitable and convenient form of dress- ing. While the patient is in the hospital he should be taught to clean the area around the tube thoroughly and to apply the dressing. For the first few days, cleaning the area with sponges soaked in benzalkonium chloride solution 1: 1000 is advisable. Later the use of soap and water is encouraged. There is consider- able variation among individuals with respect to the tolerance of the skin to the acid gastric juice, and some have no trouble at all. Irritation can be kept at a minimum if the area is cleaned as often as necessary. A mild ointment such as zinc oxide, lanolin or castor oil may be advisable in some cases. Heavy pastes should be avoided; they are hard to remove and, therefore, there is greater chance that the essential cleansing with soap and water will be neglected. The care for each patient should be outlined according to his individual need. When the hospital stay has been too short to insure adequate learning, then the nurse should refer him either to a nurse of his own choice or to the public health nurse for further instruction. In many instances, the care of a patient, especially a child, with a lye stricture is a long-term problem. There may be repeated hospitalizations and operative procedures. During this period efforts must be made to prevent the patient from becoming a chronic invalid. Regular education must not be neglected, and family relationships and responsibilities must be somehow con- tinued. TRACHEOESOPHAGEAL FISTULA This condition, in which there is an open communication between the trachea and the esophagus, is usually congenital and produces serious symptoms in the newborn infant. Occasionally the lesion occurs later in life as a complication of tuberculosis, cancer, or trauma. As soon as the newborn infant begins swal- lowing, usually on the occasion of the first feeding, the milk runs into the trachea. Coughing, Cyanosis, aspiration pneumonia, and even asphyxia may result. Death is inevitable unless the com- 218 NURSING IN SURGERY OF THE ALIMENTARY TRACT munication can be successfully closed by operation. Needless to say, the intrathoracic operative procedure which must be done is very hazardous in the case of a newborn infant, and the mor- tality rate is high. Gastrostomy is routinely performed for feed- ing. Nursing Care. The nursing care of the inſant is directed to- ward preparation for operation by prevention of any further aspiration of mucus and fluid and, at the same time, to treat the existing pneumonitis and atelectasis. Fluids by mouth are with- held. Antibiotics are administered and oxygen therapy is pro- vided. Dehydration is overcome by the use of parenteral fluid. Prevention of aspirating mucus from the accumulation in the mouth and pharynx is accomplished by adequate sucking of the mucus [rom the mouth by means of a suction device. A catheter (No. 8 French), attached to the suction apparatus, is introduced into the pharynx as often as necessary. In some patients, Constant suction is applied. The suction should not be too strong. The baby must never be left alone. Choking and cyanosis must be prevented. The treatment is continued until the surgeon feels that the condition of the baby is such that he may operate. Following operation either constant or intermittent hypo- pharyngeal Suction is used, depending upon the amount of secre- tions present. The baby is given oxygen for at least twenty-four hours and antibiotics are administered as ordered. About six or eight hours after operation, gastrostomy feedings are begun by giving the baby small amounts of water and then increased amounts of formula are given as ordered. To ſeed through the gastrostomy, the nurse inserts an Asepto syringe in the end of the gastrostomy tube, and adds the water or formula before releasing the clamp on the tube so as to prevent air from entering. After the formula is introduced, a small amount of water should always be added so that all of the formula will be delivered into the stomach. Before removing the Asepto syringe the clamp is reapplied to the gastrostomy tube. The baby should be observed for distention following the feeding. This may be prevented by holding him upright aſter each feeding. The dress. ing around the tube should be inspected frequently and changed when it is wet. The skin surrounding the tube may become irri- tated from the gastric juices. This may be prevented by daily, thorough cleansing of the skin with aqueous Zephiran solution 1:1000 followed by the application of a soothing ointment. A NURSING IN SURGERY OF THE ESOPHAGUS 219 satisfactory ointment for this purpose may be made by mixing castor oil 150 gm.; zinc oxide, 30 gm.; starch, 65 gm.; and petro- latum, 125 gm. Feedings by mouth are begun when the esophageal closure is healed, usually about the seventh postoperative day. Boiled water or 5 per cent glucose is usually ordered. The nurse must guard against permitting the baby to take the feeding too rapidly and close observation should be made of the ease with which the baby swallows. Any Coughing, choking or regurgitation should be reported immediately. Holding the baby in a semi- sitting position, while feeding him, makes swallowing easier than in the recumbent position. Constant observation by a nurse is essential until the baby is able to take his feedings in the normal manner and take the amount required for an infant of his age and weight. Before the baby goes home his family must be warned that any difficulty arising when the baby swallows should be reported to the Surgeon. ESOPHAGEAL DIVERTICULA The term diverticulum means a little outpouching. Diverticula are common lesions of the alimentary tract, occurring at any point; esophageal diverticula are second in frequency only to those of the large intestine (colon). Diverticula occur wherever the muscular coat is thin normally, or when it is thinned out by wear and tear or disease; a tiny opening permits a small pocket of mucosa to protrude just as the inner tube of a tire might herniate through a hole in the casing. As the result of the gradual accumulation of food, fluid, and gas, the diverticulum gradually enlarges; pressure of the enlarging diverticulum produces either regurgitation or progressive obstruction, or both. Diagnosis is based upon those symptoms, and is confirmed by observation of the orifice of the diverticulum by means of the esophagoscope and by demonstration of the diverticulum on the roentgen film after a swallow of barium. A sizable diverticulum of the cervical esophagus may, if filled, be actually seen and felt in the neck by the examiner. Treatment. The only successful treatment is surgical removal. There is little risk associated with the surgical removal of a diverticulum of the cervical esophagus, but, as might be ex- pected, the risk is greater when dealing with a diverticulum of 220 NURSING IN SURGERY OF THE ALIMENTARY TRACT £3%/ lº "4% % Ǻ % }\ £º Yº 1: § % V. % ſ l 3 ū V \ º Esopha; 221 à-1 diverticulum § onstricting º §A tha, º FIGURE 67. Diverticulum of esophagus. Observe how expansion of the diverticu lum may cause compression of the esophagus. the intrathoracic portion. Breakdown of the surgical closure of the esophagus, with consequent fistula formation and infection of the mediastinum, is likely to be disastrous. Nursing Care. In Contrast to all other patients with esophageal disease, the person with a diverticulum of the esophagus appears to be in good health. He has not lost weight and he is not de- hydrated. When the patient is ordered to have an esophagoscopic exam- ination, the preparation and care following are like that de- scribed for bronchoscopy (p. 115). Preoperative care is given in the routine manner. Preparation to receive the patient following operation in- cludes the regular postoperative unit. It is advisable to have suction equipment at hand to remove excess secretions in the throat. Observing the patient's pulse, rate of respiration, temperature and blood pressure are essential. The dressings should be ob- served for bleeding. Oozing of serosanguineous fluid may occur through the opening left in the incision by means of a drain. NURSING IN SURGERY OF THE ESOPHAGUS 221 Turning the patient and making him cough every hour for at least twelve hours help prevent atelectasis. As soon as the patient is well oriented he should be told that he should not drink or eat anything and that he should expec- torate mucus and excess saliva. Fluids are usually withheld about four days, then tap water is cautiously administered. Clear liquids are given about the sixth day, soft diet on the eighth day and a regular diet on the tenth day. The patient is usually permitted out of bed on the second postoperative day, and may be discharged as early as the seventh day. Instruction from the nurse and dietitian concerning diet should be reinforced with a diet list printed or written out for the patient. His return visit is usually only a few days after discharge. A return slip and instructions as to the time and day he should return to his doctor are given the patient so that good follow-up care may be given. ACHALASIA OF THE ESOPHAGUS In this relatively uncommon condition, also known as Cardio- spasm, there is progressive obstruction to the passage of food and fluid at the junction of the esophagus and the stomach. The cause of this peculiar malady is not known. Regurgitation of increas- ing severity occurs, and malnutrition to the point of actual starva- tion follows. The enormous enlargement of the lower esophagus is readily demonstrated by roentgenography. Some patients are successfully treated by the passing of bougies which stretch the narrowed lumen, others may be cured by operation. TUM ORS OF THE ESOPHAGUS The recent progress which has been made in the treatment of esophageal neoplasms is one of the more encouraging develop- ments in cancer therapy. Most of this recent progress is a by- product of the development of the field of thoracic surgery. The esophagus is lined by epithelial cells that resemble those of the skin and oral cavity, and, therefore, the commonest neoplasm is a squamous cell epithelioma. The symptoms of increasing difficulty in swallowing solid food and loss of weight in a person over 45 should suggest cancer of the esophagus to the examiner. Diagnosis is confirmed by di- rect inspection of the esophagus by means of the esophagoscope and tissue for microscopic examination is taken from any sus- pected area. In more advanced lesions, when the symptoms of ob- 222 NURSING IN SURGERY OF THE ALIMENTARY TRACT struction are more outspoken, the extent of the lesion and the degree of obstruction can be studied by roentgenography. Treatment. The operative procedure to be used depends upon the location of the tumor. In the cervical portion of the esopha- gus, which is most accessible to the surgeon, cancer is very rare. Tumors are commonly found in all portions of the intrathoracic esophagus. The esophagus does not stretch readily, and has a rather poor blood supply. Following removal of the portion of the esophagus bearing the tumor it is usually necessary to resort to one of several devices to reestablish continuity of the ali- mentary tract. One method involves the pulling of the stomach up into the chest, joining it to the resected end of the esophagus (esophagogastrostomy). This works well for the lower esophageal lesions. Another method is to substitute a length of small in- testine for the esophagus, either in the chest or under the skin of the chest (extrathoracic esophagoplasty). More recently suc- cess has followed the use of a plastic tube placed in the chest to which both ends of the resected esophagus are attached. Resection of the esophagus is carried out through a thora- cotomy incision, with all the necessary precautions incident to thoracic surgery. Surgery of such magnitude as this carries with it a considerable mortality. Without operation, however, every patient who has carcinoma of the esophagus would soon die, and die most miser- ably. With increasing experience the mortality rate of this type of surgery will become reasonably low. Nursing Care. The interval between the onset of symptoms and admission to the hospital varies, but it is usually long enough to cause emaciation and sometimes severe dehydration. Immediate care is directed toward building up the nutritional status. When only liquids can be swallowed, a high vitamin, high protein and high caloric diet should be given; ſrequently the nutrition is supplemented with parenteral ſluids. Esophagoscopy is usually Ordered; the care of the patient is like that described for bron- choscopy (p. 115). The immediate preoperative preparation is given in the rou. tine manner. Emotional support should be given according to the needs of the patient; all need kind and sincere reassurance. Since the operation is done through the chest and abdomen. the patient usually will return from surgery with a chest catheter and Levin tube. Oxygen is usually administered until the pa. tient becomes accustomed to the alteration of the chest contents NURSING IN SURGERY OF THE ESOPHAGUS 223 brought about by the stomach or jejunal and esophageal anas- tomosis. Oxygen therapy and Levin tube suction are frequently discontinued the second day. Tap water in small amounts (30 cc.) is ordered on the second or third day and clear liquids alternating with tap water may be ordered up to 45 or 60 cc. by the third or fourth day. When the patient complains of fullness he should not be urged to take the fluids and this should be reported. He will be able to take fluids better when sitting up than when lying flat. Regurgitation sometimes occurs when he lies flat in bed. Food is given sparingly until the seventh to tenth day when healing of the suture line has taken place. The patient should be taught the value of good nutrition, and how to arrange a high caloric intake in small amounts. Large amounts of liquids will cause fullness and should not be taken at the expense of small amounts of food with a high protein, carbohydrate and fat content. The difficulty the patient may have in maintaining his weight may be lessened if he knows how to handle his dietary problem in the most effective manner. Re- gurgitation may be prevented if the patient knows that he should not lie down for two hours after a meal. Some patients are operated upon for palliation only; this per- mits them to eat in the normal manner for the rest of their lives, and allows association with family and friends at the table, a very important factor for morale building. Follow-up care is necessary to evaluate the status and to permit help from the surgeon if any difficulties arise. SUMMARY The esophagus is no longer an inaccessible organ and surgeons can now repair, remove, and replace this structure. Care of pa- tients undergoing esophageal surgery always involves attention to respiration and nutrition. The results of the treatment of esophageal cancer are discouraging, largely because patients seek treatment late in the disease. VOCABULARY REVIEW stricture diverticulum esophagoplasty gastrostomy achalasia tracheoesophageal bougie esophagogastrostomy fistula SUGGESTED READING 1. Battersby, J. S., and Greve, Mary L.: Modern Treatment of Atresia of Esophagus. Am. J. Nursing, 50:158–161 (March) 1950. 224 NURSING IN SURGERY OF THE ALIMENTARY TRACT 2. Edgerton, Milton T.: One Stage Reconstruction of the Cervical Esophagus or Trachea. Surgery, 31:239–250, 1952. 3. Diller, Doris: Nursing Care in Esophageal Conditions. Am. J. Nursing, 47: 811–813 (December) 1947. 4. Garlock, J. H.: The Re-establishment of Esophagogastric Continuity Fol lowing Resection of Esophagus for Carcinoma of the Middle Third. Surg., Gynec. & Obst., 78:23–28 (January) 1944. 5. Haight, Cameron: Congenital Atresia of the Esophagus and Tracheo- esophageal Fistula. Surg., Gynec. & Obst, 84:504-506 (April) 1947. 6. Longmire, Wm. P.: Esophageal Conditions and Their Treatment. Am. J. Nursing, 47:807–811 (December) 1947. 7. Loveland, Dorothy: Endoscopy. Am. J. Nursing, 47:732–734 (November) 1947. CHAPTER 22 Nursing in Abdominal Surgery Since the major portion of the alimentary tract and its associated organs lies within the abdominal cavity, it follows that most of the surgery performed upon the tract is included in the field of abdominal surgery. The operative procedure of opening the ab- dominal cavity is called laparotomy. Well-trained surgeons know many ways of entering the abdominal cavity and a great variety of operations upon the viscera inside the cavity; success depends in large part upon skill in selecting and carrying out the proper one. It is a fact, nevertheless, that there are certain principles common to all of these operations; surgeons have them Constantly in mind, and nurses function far more capably iſ they too know them. Anatomy of the Abdominal Wall. The abdominal cavity is sheathed in a thick, muscular wall that is supported from above by the ribs, posteriorly by the spinal column, and below by the bony pelvis. On each side, attached to the lower ribs, to the tough, fascial covering of the spinal muscles, and to the crest of the pelvis are three muscles, overlying one another. The fibers of the outermost (external oblique) run from the side down toward the midline; the fibers of the middle one (internal oblique) run from the side up toward the midline, at right angles to the first; and the fibers of the inner muscle (transversalis) run horizontally NURSING IN ABDOMINAL SURGERY 225 across the abdomen. Each of these three muscles is attached to its mate ſrom the opposite side of the abdomen by means of a tough, fibrous fascia which also serves as a sheath for the fourth set of abdominal muscles. This last set (rectus abdominis) runs in a vertical direction, from the sternum and lower ribs down to the pubic bone on either side of the midline; these are the muscles which are readily seen in persons of an athletic build. These sets of muscles constitute a wonderfully strong arrange- ment, for there is a muscle to meet a pull or a stress in any direction. All of them are activated by the spinal nerves, a fact of much importance, for division of a nerve is followed by paral- ysis of a corresponding segment of muscle. The size and tone of these muscles vary from person to person. A young, athletic individual usually has heavy, strong muscles, whereas a thin, middle-aged woman who has borne many chil- dren is likely to have a relaxed, flabby abdominal wall. The effect of the position of a patient is worthy of consideration. One might think that the abdominal muscles would be most relaxed when the distance between ribs and pelvis is the shortest, as in the semi-sitting (Fowler's) position; actually this is not the case, as a little self-study will show. The abdominal muscles are best relaxed when the patient is lying flat on his back with the thighs flexed and supported by means of a pillow beneath the knees. Anatomy and Physiology of the Peritoneum. This glistening, smooth membrane resembles the pleura and the pericardium and, like them, is composed of endothelial cells. The peritoneum lines the abdominal cavity and also forms the outer covering of the viscera which lie within the peritoneal sac. The peritoneal sac Corresponds roughly to the abdominal cavity, but is not iden- tical with it, since there are several important organs which, although in the abdomen, lie wholly outside of the peritoneal sac and do not have any peritoneal covering. There are other structures which lie beneath the peritoneum but are covered in part. The chief function of the peritoneum is to provide a smooth, slippery surface so that the movements produced by the contrac- tions of the muscular walls of the different portions of the ali- mentary tube (peristalsis) may be frictionless and unimpeded. There is, actually, no ſree space in the peritoneal cavity under normal conditions, for the viscera are closely packed together, the peritoneal surfaces are in contact, and one portion of the ali- mentary tract expands in size only at the expense of another, or 226 NURSING IN SURGERY OF THE ALIMENTARY TRACT as the whole abdomen expands. Anyone who has ever eaten a hearty meal can attest to this last fact. The peritoneum is endowed with great reparative power, and the speed with which it heals helps to make intestinal surgery safe. If, following an incision, the peritoneal edges are carefully approximated, the line of closure will be watertight and airtight within a few hours. Under such conditions healing is probably complete in about eighteen hours, and the healed peritoneum cannot be distinguished from the original since this membrane heals by regeneration and not by scar formation. Interestingly enough, this same remarkable power of rapid agglutination and healing may be a menace as well as a help, for small or large por. tions of the peritoneum, damaged by disease or trauma, may be: come adherent on contact, thus forming the justly dreaded ad- hesions. Lymphatics are richly distributed throughout the peritoneum, and absorption of soluble material is rapid. The inflammatory response (peritomitis) to infection or other irritants is both prompt and effective. The parietal peritoneum is well supplied with sensory nerve endings; the visceral peritoneum is less sensi- tive, but pulling (traction) upon any part of the peritoneum causes severe pain and may even produce shock. An atomy of the Abdominal Viscera. It will aid in understand- ing the various folds of the peritoneum and the attachments (mesenteries) of the stomach and intestines if one recalls that early in the embryologic development of the human being all of the organs lie behind the peritoneal sac. During growth, some of them, notably the stomach, intestine, and liver, push forward, so that they become covered by peritoneum on all surfaces except where they are attached posteriorly to the large blood vessels. The small and large intestines, however, continue to elongate, and this can be accomplished only by the production of loops or coils. Thus the small intestine, which is many times longer than the abdominal cavity, comes to lie in loops or coils which are practically free in the cavity, being attached only by their blood vessels. As these coils have pushed out into the peritoneal cavity, their covering of peritoneum has come along with them, so that the intestine and its vessels are entirely sheathed by the membrane. The fanlike attachment of the bowel, composed of the vessels with peritoneum on both sides, is the mesentery of the small intestine. The large intestine is not so long, and instead of being thrown up into coils, it is rotated into a loop that NURSING IN ABDOMINAL SURGERY 227 aſº. tº * y & A ſº ºt ſº *...*. § ºf A fº §§ \ | Goll- () Uğ t , | (Great Sº .." %fº º * | ſºſ $ º bledder ºr ) §i) § tºsſ. tº ('ſº Asc colo , O n º sºt Ulriſh § S-. & Sº i 2. 51mall N ©\adder- 24/ 1TYtest ling - +----— ” \-- - -. •= elº £ FIGURE 68. The abdominal viscera, seen from the front. travels once around the periphery of the abdominal cavity. This portion of the bowel is not thrust completely forward into the cavity; therefore the anterior half only is covered by peritoneum, with two exceptions: the transverse colon is pushed down into the cavity by the stomach, and the lower descending Colon (sig- moid) is elongated, so that both of these portions have well- developed mesenteries and are almost completely sheathed in peritoneum. The surface of the liver, except the portion attached to the diaphragm, is covered by the peritoneum. The pancreas and kid- neys, however, remain entirely behind the peritoneum, as do also the adrenals, the ureters, and the great vessels. The spleen, in reality an oversized and modified lymph node with no known digestive function, lies free in the peritoneal cavity save ſor its pedicle of blood vessels. Anomalies. It is not surprising, considering the complicated arrangements of the viscera, that abnormalities due to maldevel- opment are common. The different organs may be out of place, poorly or incompletely developed, or even absent. Some of these 228 NURSING IN SURGERY OF THE ALIMENTARY TRACT developmental anomalies are remediable, some are not; others are of interest only as they are significant in the understanding of abdominal symptoms and signs. An example of this last is situs inversus, in which all the positions of the organs are reversed, the liver being on the left, the stomach on the right, and the appendix on the left. ABDOMINAL DIAGNOSIS How does the surgeon know when to operate, and how does he know where to make his incision? These decisions are based upon his interpretation of the patient's symptoms, the signs ob- served upon physical examination, and the results of laboratory studies and certain special examinations. In gathering and evalu- ating these facts, all who come into contact with the patient can be helpful to the surgeon; the greater the nurse's understanding, the greater her usefulness. - Symptoms. The Commonest complaint is pain. There is prob- ably no one who has not had some kind of an abdominal pain at One time or another. Much is to be learned, however, from care ful investigation of the complaint: what kind of a pain is it, where is it felt, does it stay in one location or radiate, how long has it been present, is it continuous or intermittent? Clinical ex- perience has shown that certain types of pain are characteristic of Certain Conditions. Thus, Cramplike pain indicates violent muscular Contraction; excruciatingly sharp, Continuous pain usually is caused by the sudden distention of a hollow viscus; Continuous abdominal pain that is aggravated by the least motion of the abdomen points to peritoneal inflammation (peritonitis). Since the peritoneum and the abdominal viscera are served by sensory fibers derived from the lower spinal nerves, the location of the pain gives a clue to the organ involved. It must be remem- bered, however, that more than one organ may derive its sensa- tion from the same intercostal nerve. In general, upper ab- dominal pain is produced by abnormalities of the stomach, liver, gallbladder and bile ducts, spleen, and pancreas. Pain in the region just above the umbilicus suggests trouble in the small in- testine, whereas pain around the umbilicus or below it is likely to be caused by lesions in the large intestine, including the appendix. There is an important group of symptoms related to abnor- mal function of different portions of the alimentary tract, in- cluding belching (eructation), vomiting, passage of gas by rectum NURSING IN ABDOMINAL SURGERY 229 (ſlatulence), constipation, diarrhea, loss of appetite (anorexia), and a vague disturbance that the patient usually speaks of as “in- digestion.” Each of these calls for special analysis: thus vomiting may be occasional or frequent, it may occur immediately after meals or later, and the character and amount of the vomitus are significant. Much can be learned by investigation of bleeding from the alimentary tract when that occurs. The amount of blood, the frequency of its passage, and whether it is fresh, clotted, old, or chemically altered are all observable facts which can shed much light on the position and nature of the source of the hemorrhage. Gross amounts of blood that has been partially digested before passage render the feces black or tarry in appearance; minute traces of such changed blood can be detected by the sensitive chemical reaction to benzidine or guaiac. Signs. Inspection is the first step in carrying out the physical examination of the abdomen. The presence or absence of nor- mal breathing, distention, visible peristalsis, and localized protu- berance may be observed. Next comes gentle palpation, from which information may be derived concerning the tone of the abdominal musculature, the location of tenderness (pain elicited upon pressure), and the presence or absence of tumor masses or ſree fluid in the cavity. Under some conditions various organs may be ſelt, wholly or in part, but normally this is not the case. Deeper, heavier palpation may disclose tenderness not felt on gentler pressure, and the sudden release of the pressure may cause a sudden spasm of pain, known as rebound tenderness, due to the sudden jarring of the neighboring viscera. Rebound tender- ness is present only when there is inflammation of the peritoneal surfaces. Care is also taken to investigate the umbilicus and the inguinal and femoral rings, lest an unsuspected hernia be over- looked. As a final step in examining the abdomen a digital rectal examination is performed, by which means further information is gained concerning the viscera situated in the pelvic portion of the abdominal cavity. Laboratory Studies. Specimens of vomitus and ſeces are studied in the laboratory, and chemical, microscopic, and bacteriologic procedures are matters of routine. Various tests have been de- vised to study the functions of the different organs, and these are described in detail subsequently under the discussion on the surgery of each organ. By having the patient Swallow a radio- paque substance such as barium, and by injecting it into the 230 NURSING IN SURGERY OF THE ALIMENTARY TRACT rectum (barium enema), the roentgenologist can visualize the lumen of the entire alimentary tube, a diagnostic aid of the greatest value. The lumen of the rectum and lower sigmoid can be directly inspected by means of a lighted tube (sigmoidoscope), and a flexible instrument has been devised which can be passed into the stomach. Through this instrument (gastroscope) a large part of the interior of the stomach can be directly observed. In- deed, a considerable portion of the peritoneal cavity itself can be inspected through a special instrument (peritoneoscope) which is introduced into the cavity through a tiny incision. Decision to Operate. The surgeon is ready to operate when evidence sufficient to make a diagnosis has been gathered. Oſten the information obtained from the history and physical exam ination is enough; sometimes, however, a positive diagnosis can not be made, even aſter exhaustive studies have been carried out. Nevertheless, the surgeon is justified in performing an explora- tory operation upon such a patient iſ there is a possibility that the patient may have a lesion which can be treated surgically. This is particularl true in the case of patients who have the so- called acute or surgical abdomen. It is, in ſact, far more im portant for the surgeon to know when to operate than it is for him to know the exact diagnosis. ABDOMINAL INCISIONS In choosing an incision the surgeon's first consideration is to secure satisfactory exposure of the region Containing the struc- tures that are to be operated upon. Next in importance is Con- sideration of those factors which bear upon the healing of the wound. Nerve and blood supplies must be conserved, and undue tension or stress avoided. Thought must be given to the preven- tion of painful scars or disabling Contractures. Finally, the cos- metic appearance should be considered. Midline, Transverse, and Rectus Incisions. In order to expose the upper abdominal viscera three different incisions are com monly used, midline, transverse or subcostal, and rectus. Fol operating upon the stomach or transverse Colon, the midline in- cision is ideal: exposure is good, no important nerves or blood vessels are divided, and there is little or no strain on the wound after operation. For exposure of the pelvic organs a low midline incision is best, and the exposure is ſurther improved by the use of the Trendelenburg position (Fig. 70). The midline incision does not afford easy access to the struc. NURSING IN ABDOMINAL SURGERY 231 *** * / \/\ * a * & * As / * *~ / \ ^-- / S__--|--D `-->. F------ * / * .* * - ~ * --- *== E-—— ~~~E T--- -—s Zºy Cs ,” ~f *s 2-ºxº f S- _--T \ | { SS e” ſ \ \ _--~ } ; \ \ _-T a f A. S- (–2/ FIGURE 69. Abdominal incisions. A, Subcostal; B, paramedian; C, McBurney: D, high midline; E, transverse; F, low midline. tures on either side, however; for procedures on the biliary tract, a right transverse incision, and, for approach to the spleen, a left transverse incision, are better. In the transverse incision the belly of the rectus abdominis muscle is divided transversely, but care is taken not to injure the nerve supply. The muscle receives its blood supply from both ends, so that division of the vessels at the incision does not impair the blood supply. This incision heals well, and the eventual scar is the least Conspicuous of any. The rectus incision is made parallel to the long axis of the muscle, and, since it can be made as long as desired, good ex- posure is obtainable. The direction of the incision, however, makes it impossible to prevent the division of the nerves supply- ing the fibers between the incision and the midline, and this fact explains the relatively high incidence of hernias that follows rectus incisions, for there is likely to be a permanent weakness wherever the muscle fibers are paralyzed. A modification of the rectus incision has been devised which overcomes this objection. The rectus sheath is divided near the midline, but instead of dividing the muscle fibers, the whole muscle belly is retracted laterally, exposing the posterior sheath and peritoneum. This is 232 NURSING IN SURGERY OF THE ALIMENTARY TRACT FIGURE 70. Trendelenburg position. Note use of shoulder braces to prevent slipping of patient. known as a paramedian incision, and it is useful in the mid and lower abdomen, too. McBurney Incision. An excellent incision that has a wide range of useſulness is the muscle-splitting (McBurney) incision. This is used for the approach to structures in the mid and lower lateral portions of the abdomen, notably for the exposure of the appendix, the ureters, and the sympathetic ganglia. The skin is incised in an oblique direction, parallel to the fibers of the ex- ternal oblique muscle. The fibers of this muscle are split, not divided, exposing the internal oblique muscle; its fibers, in turn, are split, exposing the transversalis; the fibers of this innermost muscle are likewise split, and the peritoneum is exposed. There is no damage done to muscles, nerves, or blood vessels, and when the retractors are withdrawn the muscles fall back into their normal positions, each Covering the opening in a different direction and thus affording a very strong closure, for the contraction of the muscles tightly closes the wound. Closure. The Closure of abdominal incisions is Commonly accomplished in layers: the peritoneal edges are approximated first, then the muscles, the fascia, and finally the skin. Some surgeons prefer to use sutures of catgut, others prefer sutures of silk, Cotton or stainless steel wire; good results are obtainable NURSING IN ABDOMINAL SURGERY 233 with any of these if they are properly used. When the surgeon anticipates the collection of blood or serum in the wound, or wishes to provide for the escape of pus, a drain is left in the wound. POSTOPERATIVE NURSING CARE OF LAPAROTOMY PATIENTS Dressings A clean wound that has been tightly closed without drainage need not be dressed until the fifth or sixth postoperative day, at which time the surgeon will usually remove the skin sutures. The nurse must have ready and sterilized, in addition to the proper dressings, adhesive tape, and solutions, dressing forceps without teeth, and sharp-pointed scissors. Stay sutures, if used, are generally removed on the tenth to fourteenth postoperative day. As a rule, all dressings over the healed wound can be dis- continued two or three days after the last sutures have been removed. Wounds which are open and draining pus, bile, or other ma- terial need frequent dressing, daily at least, and often every few hours. When a wound must be dressed daily or oftener the nurse usually does it, and she will do well to have the surgeon show her exactly what he wishes done. It is convenient to have an individ- ual tray set up ſor such a patient, with a sterile clamp, sterile sponges in a jar of aqueous benzalkonium chloride 1:1000 solu- tion, sterile dry sponges, and suitable dressings. After the soiled dressing has been removed, the incision and the area around it are cleaned by sponging, dried, and a fresh dressing applied. Since frequent removal and replacement of adhesive tape are hard on the patient as well as uneconomical, other methods of holding the dressings in place are more suitable. If Montgomery straps are used, the adhesive tape, when soiled, should be changed. After it is removed, there is often some adhesive sub- stance left on the skin. Benzine or ether may be used to clean this off the skin, but the area should be washed with soap and water beſore adhesive tape is again applied. A convenient type of drainage dressing is shown in Figure 50. Various types of drains, packs, and tubes are used in abdominal wounds, depending on the nature of the surgery performed. The nurse should ask for and receive specific instructions as to the care and handling of these. Mention will be made of some of these later. 234 NURSING IN SURGERY OF THE ALIMENTARY TRACT Mecisures Which McIy Prevent Complications Although a great variety of surgical procedures are carried out within the abdominal cavity, there are many complications common to all laparotomies. The incidence of many of these complications can be reduced by proper nursing care and their treatment rendered more successful by the promptness with which the nurse recognizes and reports these complications to the surgeon. The need for special observation of postanesthetic patients has already been discussed in Chapter 8. The patient is grateful for a good back rub, smooth sheets, and a fresh pillow. The pressure of tight or heavy bedclothes upon the patient's feet is avoided by the use of a frame or a pillow beneath the covers at the foot of the bed. Slight elevation of the head of the bed often makes the patient more comfortable, but Fowler's position should not be used unless specifically prescribed by the surgeon. The elevation of the knees and flexing of the thighs incident to Fowler's position tend to bring about stasis of the blood stream, especially in the popliteal and pelvic vessels. It has been postulated that this might increase the incidence of postoperative thrombosis, and therefore many surgeons prefer their patients to be flat in bed aſter laparotomy. Relief of Pain. Every patient is going to have pain, really severe pain, during the first day or two. Hypodermic injections of morphine or other narcotics should be given every four to six hours during the first twenty-four hours after operation, as it is to the patient's advantage to rest quietly and comfortably during that period. In ordinary cases, aſter the second or third day, smaller doses or less strong narcotics are used and then only when necessary. Change of Position. A simple measure which may accomplish much is the frequent shifting of the patient's position. In this way no single portion of the lungs remains dependent for long, a fact which helps to prevent atelectasis or pulmonary inſections, Or both. At the same time the return ſlow of blood from the extremities and lower abdomen is facilitated, as a result of which there is less chance of thrombosis in the large veins and the in- cidence of embolism is lowered. There is a ſavorable effect upon intestinal tone and upon the expulsion of ſlatus. Finally, by avoiding long periods of pressure upon the skin that overlies the bony prominences, bedsores (decubitus ulcers) are prevented. A NURSING IN ABDOMINAL SURGERY 235 sick patient needs help in moving about, particularly if move- ment is painſul, as it nearly always is during the first two or three days aſter laparotomy. He should be encouraged to move slowly and careſully, and to allow others to help him change his position. These patients should be helped on and off the bedpan with particular care. Prevention of Afelectasis. A patient who has a sore abdomen is not going to take a deep breath if he can help it, but such re- striction of the respiratory excursion of the lungs favors the production of atelectasis. Such patients can and should be made to expand the lungs ſully at intervals. To effect this the surgeon usually orders the patient to be turned and required to Cough and breathe deeply at hourly intervals for the first twelve to eighteen hours aſter operation. Common Postlqpdrofomy Complications Vomiting. During the period of recovery from anesthesia vom- iting is probably the commonest complication. Aspiration of the vomitus must not be permitted. The vomitus must be inspected for blood and measured so that the effect upon fluid balance can be determined. When postoperative vomiting persists beyond the first day some cause other than the effect of the anesthetic agent must be suspected and found. Vomiting should be suppressed as much as possible, for the violent straining incident to it is harm- ful to wound healing, and is likely to start up fresh bleeding in the operative region. Sedatives, quiet, inhalation of carbon dioxide, strong suggestion, and gastric suction aid in controlling vomiting. Hiccough. HiCCough (singultus) can be an extremely distress- ing Complication and, if persistent, severely taxes the strength of the patient and jeopardizes the healing of the wound. Any of the measures used in controlling vomiting will, at times, control hiccoughing; of these, gastric suction is the most successful. The appearance of persistent uncontrollable hiccoughing, although its cause is not understood, is generally regarded as an ominous sign so far as the prognosis of the illness is concerned. Bleeding. The dressings are to be inspected often so that bleeding or other drainage may be promptly discovered and re- ported. Internal bleeding is suspected if blood is passed by rec. tum, or is vomited, or if there is a significant change in the rate or quality of the pulse. Wound Disruption. The role of infection in preventing wound 236 NURSING IN SURGERY OF THE ALIMENTARY TRACT healing has been discussed in an earlier chapter; occasionally, however, even in the absence of demonstrable inſection, an ab- dominal wound ſails to heal as it should. The reasons for this are still obscure, but probably include too much motion of the abdomen and longstanding dietary deficiency. The sudden ap- pearance of a considerable amount of straw-colored serous drain- age Irom a wound which was apparently healed should lead the nurse to suspect a breaking down of the wound (disruption, dehiscence). This often occurs shortly aſter the removal of the skin sutures, and is usually precipitated by Coughing or other strenuous exertion. A quick look beneath the dressing discloses the wound disruption; in some instances omentum or loops of in- testine are extruded (evisceration). The wound and viscera should be quickly covered with sterile towels moistened with sterile physiologic saline solution, after which the patient must be taken to the operating room for reclosure of the wound. Con- trary to what one might expect, such wounds, when resutured, usually heal promptly, and most of these patients eventually ICCCOV6Iſ. Difficulty in Voiding. This is another usual Complication. It is understandable: some of the muscles involved in the act are apt to be painful; there is little or, at best, precarious privacy in a hospital; and nearly everyone, ſrom the earliest infancy, has become accustomed to voiding in the upright position. Tactful handling and a few simple procedures are successful in getting the majority of patients to void after operation, but some require catheterization. The patient's worries and fears should be al- layed, and he should be given as much privacy as possible. Warm- ing the urinal or bedpan, applying a hot water bottle to the pubic region, or the application of warm water to the genitalia is often helpful. When not contraindicated by the nature of the operative procedure, a small-sized warm enema (not over 112° F.) or the administration of a parasympathetic stimulant such as Prostigmin is usually successful. Male patients, when possible, should be permitted to stand. Once the patient has gotten started he is not likely to have further trouble. It is interesting that the patient most apt to have difficulty is the one who is certain before operation that he will have trouble; those who do not give it a thought are seldom unable to void. Unless the patient has taken large amounts of fluids or is ex- tremely uncomfortable it is generally safe to allow eighteen or NURSING IN ABDOMINAL SURGERY 237 twenty-four hours to elapse after operation before resorting to catheterization; a longer period is likely to result in dangerous dilatation of the bladder. Distention. A Common Complaint of many patients after a laparotomy is “gas pains.” This symptom occurs during the first two or three days after operation; and the nature of its cause is discussed on page 242. The distention and pain incident thereto are relieved by changes in position, the use of the rectal tube, and by enemas when the latter are not contraindicated by the nature of the operation which has been performed. Con- tinuous gastric suction drainage prevents “gas pains,” and early ambulation appear also to have a beneficial effect. Convcılescent Core Convalescent care! is based upon the surgery performed, and upon the reaction of the individual to it. Consideration of his needs and progress will determine the diet, the time for ambula- tion and guidance necessary to prepare him for discharge. The value of early ambulation has been mentioned previously (page 96). Food. It is better, in general, to increase the diet gradually. Unless the type of operation performed requires a special pro- gram, liquid diet the first day, soft diet the second, and diet as desired thereaſter are satisfactory. During the first few days, the patient should not be urged to eat more than he desires; ſluid balance should be kept up with parenteral therapy if neces- sary. Permitting him to choose his diet is advisable; too often it is taken for granted that the patient has a poor appetite, whereas questioning might reveal that he merely has a dislike for the par- ticular diet offered. Encouraging the patient to voice his opinion concerning his diet is often very helpful in promoting proper nutrition and also offers the nurse an opportunity to begin ex- plaining the essentials of well-balanced meals. Finding out what the patient ate at home is essential. A patient may be well in- formed about the daily requirements for good nutrition but, by and large, explanation Concerning the components of a well- balanced diet is advisable. In addition, planning should include substitutions for the foods the patient dislikes. A knowledge of how food costs may be reduced by utilizing alternative sub- stances is practical and often important for the management of 1 Sec Brown, pages 36–58. 238 NURSING IN SURGERY OF THE ALIMENTARY TRACT an adequate diet in the home. The nurse and patient should plan together but a feeling of independence should be developed in the patient. Planning Total Care. During the days following operation, the nurse must learn from her patient the factors important for continuity of care. The patient's general condition, his problems and his relation with his family are aspects of prime importance in guiding him to meet his needs. How he will be cared for when he goes home is a vital part of total care. Dressings to be changed, special medications to be given and plans for the re- turn visits are some of the aspects of care which should be con- sidered before the moment of the discharge order. Planning with the patient and his family will encourage independence and al- leviate anxiety. Sometimes treatments may require additional help in the home. In such a case the doctor, nurse and patient plan for their execution. The doctor may wish that the treat- ments be given by a professional or practical nurse. The nurse should then arrange with the help of the family and doctor to provide such care, but, if the treatments are to be carried on by a member of the family, the nurse should undertake the neces. sary instructions and demonstrations to insure proper care. SUMMARY In any general hospital a large proportion of the major surgery is within the field of abdominal surgery. In rendering care the nurse is greatly aided by a knowledge of the anatomy of the abdomen and the physiology of the gastrointestinal tract. Good nursing prevents complications and minimizes unpleasant symp. toms. A vital part of the nursing function is aiding with the plan for total care. VOCABULARY REVIEW peritoneum eructation Trendelenburg laparotomy flatulence position viscera anorexia hiccough mesentery distention SUGGESTED READING 1. Christian, Theresa: Nursing Care in Abdominal Surgery. Am. J. Nursing, 50:797–798 (December) 1950. 2. Cooper, Lenna F., Barber, Edith M., and Mitchell, Helen S.: Nutrition in Health and Disease. 11th Ed. Philadelphia, J. B. Lippincott Co., 1950, pp. 383–385. PERITONITIS AND ILEUS 239 3. Palumbo, Louis T.: Some Recent Advances in Surgery. Am. J. Nursing, 50: 658–661 (October) 1950. 4. Sheldon, Nola S., and Blodgett, James: Early Rising in Postoperative Care. Am. J. Nursing, 46:377–378 (June) 1946. CHAPTER 23 Perifonitis and Ileus PERITONITIS A little more than fifty years ago, peritonitis was a word to cause grave head-shaking among physicians and to strike terror to the hearts of patients' families. The onset of fever, the quickening of the pulse, the rigid, painful abdomen, and the flushed, drawn face were signs well known to Hippocrates, but it remained for Lister to show surgeons how to operate safely within the abdo- men; it remained for Reginald Fitz and John B. Murphy to dem- onstrate that many cases of peritonitis were due to the perfora- tion of an inflamed appendix and could be prevented by early removal of that appendix; and for present-day surgeons to show how the concomitant intestinal obstruction (ileus) due to the inflammation of the intestine could be successfully combated, and how chemotherapy could be successfully used against the infection itself. Abundantly supplied with lymphatics, the peritoneum pre- sents a vast surface capable of rapid absorption. One result of this is the prompt systemic reaction to toxins or other deleterious agents produced by the bacterial invaders. High fever, rapid pulse, and prostration occur in acute suppurative peritonitis. An equally serious feature is the loss of the tone and contractility of the intestinal musculature. A form of intestinal obstruction (para- lytic ileus) is the result of this paralysis of intestinal activity; intestinal contents accumulate just as though there were an actual barrier to their passage; distention follows and may lead to necrosis of the bowel wall with perforation. Paralytic ileus introduces the further complications of vomiting, fluid loss, electrolyte imbalance, and starvation. It is not hard to see why untreated peritonitis is a highly fatal disease. 240 NURSING IN SURGERY OF THE ALIMENTARY TRACT Inflammation of the peritoneum (peritonitis) is caused by a wide variety of agents, including pathogenic bacteria, certain viruses, chemical irritants, and free blood. Since none of these is ſound in the peritoneal cavity under normal conditions, it fol. lows that peritonitis must always be the result of either an injury or a disease that provides a portal for the entry of the etiologic agent. Pathology. The peritoneum quickly loses its smooth glistening appearance, becoming dull or even red and swollen. There is exudation of fluid containing fibrin and leukocytes. In a rapidly spreading infection of overwhelming virulence (generalized peritonitis) there may be frank pus everywhere in the peritoneal cavity, but in less severe cases natural barriers to the spread of the inſection are interposed. This walling-off process is accomplished by the adhesion of opposed inflamed surfaces, and by the mar- velous protective action of the omentum—an apronlike structure of fat and blood vessels sheathed in peritoneum and hanging down from the transverse colon—which has the property of mov- ing into and enveloping an area of inflammation. Thus the peritonitis may be restricted, or localized, assuming more or less the characteristics of an abscess. Even recovery ſrom peritonitis is fraught with danger, ſor in the healing process one or more localized abscesses sometimes de- velop, and loops of intestine may become permanently adherent, leading in some instances to the development of mechanical in- testinal obstruction. Oſten, however, healing is so complete that afterward no trace of the inflammation can be ſound. Prevention. The importance of preventing peritonitis is ob- vious. Little need be said about the necessity for the strict ob. servance of aseptic technic in performing abdominal operations: that is a sine qua non. There is still great need, however, for further and Continued education so that persons with appendici. tis or other illnesses that may lead to peritonitis will early seek and obtain adequate treatment. Treatment. The clinical diagnosis of acute peritonitis is easily made; it is more difficult to ascertain the cause, yet this is most important since proper therapy depends on it. The program for treatment is fourfold: (1) eradicate the source of the infec. tion; (2) combat such infection as has already developed; (3) combat the paralytic ileus; (4) restore and maintain the pa- tient's fluid and electrolyte balance and nutrition. Ideally, all of these things should be done simultaneously, but practically, in PERITONITIS AND ILEUS 241 very ill patients, the last three items must take precedence over surgical procedures until the condition of the patient has been improved sufficiently to enabled him to withstand operation. Thus, while the surgeon still seeks to discover the cause of the peritonitis, he may begin treatment by administering intravenous fluids and antibiotic agents, and may also begin decompression of the distended alimentary tract by the use of Continuous suc- tion with an indwelling gastric or duodenal tube, introduced through the nose. Usually within a few hours there is great im- provement in the patient's condition, and the operation to re- move a perſorated appendix or whatever is necessary may be safely undertaken. When the peritonitis begins very suddenly, however, as the result of an acute perforation of a gastric or duodenal ulcer, or in a case of a penetrating wound of the abdomen, the patient is usually not too ill to undergo operation at once. In fact, it may be stated as a general rule that every patient having a perforation of an intra-abdominal viscus must be operated upon and the perſoration closed as soon as possible. When peritonitis is not the result of perforation of the ali- mentary tract, there may be no need for abdominal Surgery. Gonococcal or tubercular peritonitis is properly treated by anti- biotics, drugs and general measures, as is also the occasional blood-borne pneumococcal or streptococcal peritonitis that Com- plicates an infection which has originally started elsewhere in the body. Similarly, no operative treatment is needed for the transient peritonitis due to small hemorrhages incident to the rupture of an ovarian follicle. Often, however, a diagnosis can- not be made with certainty, and in such instances exploratory laparotomy may be necessary. Posfogerative Position. For many years surgeons have advo- cated the use of Fowler's position in the treatment of peritonitis, believing that the gravitation of the pus into the lower abdomen (pelvis) aided in recovery, since accumulations of pus (abscesses) could be more readily ſound and more safely evacuated (drained). Lately there has been less accord on this method, and some sur- geons prefer to have their patients flat; others, indeed, advocate having the patient lie upon his abdomen. Outcome. Successful treatment of the peritonitis is followed by return of the tone of the intestinal muscle and of peristalsis, usually within forty-eight to seventy-two hours. The onset of im- provement is marked by diminished output through the suction 242 NURSING IN SURGERY OF THE ALIMENTARY TRACT tube, and by the passage of increasing amounts of flatus and stool per rectum. ILEUS In the performance of any laparotomy, even though asepsis is complete and the utmost precautions are used in the gentle han- dling of the abdominal viscera, there is bound to be some slight trauma to the delicate peritoneum. Varying degrees of paralytic ileus are therefore a common complication of laparotomy. The slight distention and the uncomfortable gas pains of the first postoperative day or two are a mild form of this disorder. The extent and the severity of the peritoneal inflammation depend upon many factors, such as the nature of the causative agent, the amount of peritoneum involved, the rapidity with which the process spreads, and the interval between onset and treatment. There is need for differentiating between intestinal obstruction that is the result of an actual blocking of the lumen of the tract (mechanical ileus) and that which results from the loss of in- testinal contractility (paralytic ileus). In the first instance the mechanical barrier must be removed, the occluded lumen must be re-opened. As a rule, surgical procedures are necessary. Paralytic Ileus. In paralytic ileus the intestines become dis- tended because of the loss of muscle tone and from the accumula- tion of intestinal contents. The sources of the contents of the distended bowel are food, fluid, ingested air and the secretions of the alimentary mucosa and associated glands. There is nothing abnormal about these sources: only their accumulation is wrong. As the distention increases not only is the muscular wall over- stretched, thus delaying the return of peristalsis, but there is an additional danger in that the circulation of the bowel wall is reduced by the pressure upon it, leading to ultimate necrosis of the tissues and perforation. If untreated, distention progresses rapidly, and soon the upper intestinal tract and stomach are filled, vomiting of large amounts of foul-smelling fluid begins, and the whole vicious cycle is under way. Treatment. In paralytic ileus, surgery does not help; it may even be harmful. In mild cases, and particularly in those where intestinal tone returns in a day or two, it is often sufficient merely to restrict or prohibit the intake of fluid and food by mouth. In general, the tone of the intestinal musculature will return as the peritoneal inflammation subsides, so that treatment must be pri- marily directed toward the cure of the peritonitis. While this is PERITONITIS AND ILEUS 243 being done, however, several measures can be taken which will protect the intestinal wall and hasten the return of peristalsis. These include enemas, hot applications to the abdomen (stupes), and the administration of such drugs as Pitressin and Prostigmin. Experience has shown, however, that these are of little use until the intestinal contractility begins to return. A simple and useful procedure, and one often overlooked, is the frequent turning and moving of the patient, which has the effect of pouring the in- testinal contents from one loop to the next, sometimes with great success. The most effective measure, however, is the use of Con- tinuous withdrawal by suction of the intestinal Contents. By this means the distended alimentary tract can be decompressed, and recurrence of the distention prevented. TECHNIC OF DECOMPRESSION. If the distention is progressive, or iſ vomiting has begun, continuous decompression is the proper treat Iſlent. One of several types of tubes made of rubber or plastic material may be introduced through the nose into the stomach. The tubes used most frequently are: the Levin (No. 14 or 16 French), the Miller-Abbott and the Cantor. The Levin tube is used when the contents of the stomach are to be aspirated. The double- lumen Miller-Abbott tube has a rubber balloon at the tip inflated with air; the Cantor has a mercury-weighted bag at the tip. These devices aid in carrying the tube beyond the stomach, but are useful only if there is motility of the stomach and intestine. Before passage of the tube is begun, the nurse should explain to the patient what the necessary treatment will be to enlist his cooperation and allay fear. She should be sensitive to any anxiety and try to encourage him to voice any apprehension he may have. The necessary equipment includes: mouth wipes, curved basin, lubricating jelly, glass of water, adhesive tape and the type of tube the doctor has ordered. The tube may be inserted while the patient is in the sitting position with head forward, or in the recumbent position, with head hyperextended. The latter position seems desirable when the Cantor tube is passed. After the surgeon has introduced the tube into the nasopharynx, the patient should take a few swal- lows of water to help carry the tube into the stomach. If intuba- tion of the intestine is desired, the position of the patient is then changed every two hours as follows: (1) He is placed on the right side in Trendelenburg position while enough tube is in- serted to bring the tip to the pylorus; (2) he is placed on his 244 NURSING IN SURGERY OF THE ALIMENTARY TRACT FIGURE 71. Treatment of distention by suction. The degree of negative pressure is regulated by the thumb-screw on the valve at A. Insert at lowe right shows Miller-Abbott double-lumen tube. Insert at lower left shows tube critering duodenum. Suction may also be obtained from apparatus as shown in Figure 51, or by the water siphon method of Wangensteen, back in Fowler's position while 2 inches more tubing is inserted, which should bring the tube into the duodenum; and (3) on his leſt side with the bed flat while another 2 inches of the tube is inserted. The tube is then secured to the cheek with adhesive. X-ray or fluoroscopic examination is made to determine the posi- tion of the tube. The tube is then connected to an apparatus that furnishes Constant but gentle suction (Fig 71). Negative pressure equal PERITONITIS AND ILEUS 245 to 2 feet of water is sufficient to withdraw fluid and air. Care must be taken that the negative pressure does not exceed 5 feet of water. Excessive negative pressure may cause the tube to adhere to the intestinal wall by sucking the mucosa into the Small openings of the tube. The surgeon usually orders irrigations of the tube, using either tap water or normal saline. Instilling a measured amount of fluid (usually 30 cc.) by means of an Asepto syringe, waiting two minutes and then withdrawing the fluid with the syringe is a means of keeping the holes of the tube open. Whenever it is not possible to withdraw the fluid, it is obvious that the holes are clogged and therefore no fluid will be drained off when the tube is attached to the suction machine. This should be reported to the surgeon. Overfilling of the stomach (gastric dilatation) is a very serious complication and must not be permitted to occur. Vomiting around the tube is an indication that the suction is ineffective. In general, whenever the nurse instills fluid into the tube, she should assume that the fluid should be withdrawn and when there is no withdrawal help should be sought from the surgeon. The effect of continuous suction drainage is little short of miraculous. The tube is well tolerated by most patients, and can be left undisturbed for several days, if necessary. It has been stated before that the maintenance of fluid and electrolyte balance is an important factor in Combating ileus. In addition to parenteral fluids, medications which are fre- quently ordered are vitamins B and C. Solutions of glucose, sodium chloride, potassium chloride and protein are regularly used to maintain fluid and chemical balance. An accurate record of intake and output is essential. An output of 1100 to 1200 cc. of urine in twenty-four hours is usually a good indication of ade- quate fluid Intake. The patient needs much attention and encouragement during this time. He may complain of soreness of his throat from the tube. Good mouth care, lozenges and instillation of drops into the nasal passages are measures which can be used. The surgeon sometimes advises the patient to chew gum to stimulate the flow of saliva to prevent parotitis. Intravenous feedings are unpleasant for the patient because moving about is restricted. Too often the patient lies in one posi- tion overlong because the nurse has not encouraged him to turn. Care in turning will prevent the needle from becoming dis- lodged. 246 NURSING IN SURGERY OF THE ALIMENTARY TRACT Consideration should also be given the family when they visit the patient. The hospital personnel are accustomed to the equip- ment necessary to care for the patient but this frequently is very alarming to the visitors. Explaining it to them will relieve them of their anxiety. SUMMARY Peritonitis and its regular sequel, paralytic ileus, are still dan- gerous, potentially lethal manifestations of disease. The means are at hand to deal with these conditions. Surgery, antibiotics, gastrointestinal intubation and decompression, the restoration and maintenance of fluid and chemical balance, and good nurs- ing care are needed. VOCABULARY REVIEW ileus Levin Cantor peritonitis Miller-Abbott double-lumen intubation SUGGESTED READING 1. Blodgett, James B., and Sheldon, Nola Smith: Intestinal Suction. Am. J. Nursing, #6:90–92 (February) 1946. 2. Abbott, W. O.: Indications for Use for Miller-Abbott Tube. New England J. Med., 255:641–646 (October) 1941. CHAPTER 24 Nursing in Gastric Surgery The alimentary tract may be compared to the assembly line of a modern factory. The raw material, the food that is eaten, is fed into the mouth where it is mechanically processed into a pulp by chewing. In the mouth, too, the first step is taken in effecting the chemical breakdown of the raw materials, for saliva contains a starch-splitting enzyme. The material is then moved along into the stomach, where preparations have already been made for ſurther processing. There is a wonderful communications system in the human body, quite as good as that in any factory, and each processing plant in the digestive system is notified well in advance NURSING IN GASTRIC SURGERY 247 of the need for its activity. The arrival of the habitual time for eating or the very sight of food serves as a sufficient stimulus to initiate gastric activity. The secretory phase of gastric activity is controlled by the vagus nerves which originate in the brain and travel down along the esophagus to the stomach. The stomach completes the job of mechanical processing, and introduces a new step in the chemical processing of the raw ma- terial. The glands of the mucous membrane that lines the stom- ach secrete, in addition to mucus, both hydrochloric acid and pepsin. Pepsin is a protein-splitting (proteolytic) enzyme and, in combination with the hydrochloric acid, powerfully attacks the protein part of the food eaten, breaking it down into less Com- plex and more soluble compounds. The question may well be asked, why does not the gastric juice digest away the stomach itself? The answer is that it would do so if the stomach were not protected by the mucus-secreting membrane, and wherever the continuity of the mucous membrane is broken the potent gastric juice can and does eat away the wall of the stomach, as will be seen later, in the discussion of ulcers of the Stomach. The discharge of the pulpy, fluid mass that is the end-product of gastric digestion from the stomach into the next portion of the tract is controlled by a powerful circular muscle (sphincter) which surrounds the stomach outlet (pylorus). From time to time the pyloric sphincter relaxes, permitting the passage of a jet of gastric contents into the duodenum. The control mechanism of the pylorus is not fully understood, but great variation in activity has been observed under normal conditions in the same and in different persons. Usually, after an ordinary meal, emptying of the stomach begins in a few minutes, and within forty minutes to an hour the stomach has finished its work and all of the in- gested material has been passed along. The emptying mechanism is extremely sensitive, however, and gastric function is often de- ranged by any acute illness that a person may contract, as well as by intrinsic disease of the stomach. This is particularly true of children: it is common knowledge that almost every illness in childhood begins with an “upset stomach.” The final phase in the chemical breakdown of the ſood eaten is begun in the duodenum. The secretions of the duodenal glands, the pancreatic juice, and the bile ſrom the liver are all poured into the lumen of the duodenum. Bile is strongly alka- line, and one of its functions is to neutralize any hydrochloric acid that may come through the pylorus. Moreover, the several 248 NURSING IN SURGERY OF THE ALIMENTARY TRACT Aorto, Colloc A. à • $ 2' à SN /> -- 2. N à $ ) 'S s % N // O ş º N * % $// As & % %$/A#5 ×9 * Hepsºlº duct $/A# c5 y Cystic duct \\ Splenic A. Common bile duct, Ampulle of Vetor Pencrooſtic duct &43 FIGURE 72. Diagrammatic sketch to show intimate anatomic relations of stom ach, duodenum, biliary tract, and pancreas. Part of the stomach and the anterior wall of the duodenum have been removed for the sake of clarity. enzymes secreted by the pancreas and the intestine are efficient in an alkaline medium, and possess the ability to split protein, starch and other carbohydrates, and fats. Not only are the stomach, the duodenum, the biliary tract, and the pancreas closely integrated as a functional unit: they are also most intimately related anatomically. One branch of the aorta, the celiac axis, furnishes the arterial blood supply of all of these structures, and the venous blood from all of them passes by way of the portal vein into the liver. A glance at Figure 72 will further emphasize the contiguity of these organs. It is not surprising, then, that diseases of one of these may involve others, that the symptoms arising from such diseases are often confusing and diſ- ficult to interpret, and that surgical procedures upon these organs must be designed so that there is no crippling disturbance of function. In the past, failure to observe properly this last prin- ciple has often led to trouble worse than the disease for which the surgery was originally undertaken. PYLORIC STENOSIS IN INFANTS Vomiting that begins in the first few weeks of life and becomes progressively more severe until the baby is vomiting all or more than the quantity of fluid taken by mouth, is characteristic of NURSING IN GASTRIC SURGERY 249 hypertrophic pyloric stenosis. In babies so afflicted the pyloric sphincter muscle is greatly enlarged and thickened, so that relaxa- tion with proper opening of the pylorus is impaired or even im- possible. The cause of this condition is not known. Frequent regurgitation of part or all of a feeding is the rule rather than the exception in nearly every newborn baby, but persistent vom- iting should lead the attending physician to suspect pyloric stenosis. Diagnosis may be confirmed by the observation of an en- larged stomach, visible through the abdominal wall; by palpation of the hypertrophied pylorus; and by the introduction of a small quantity of barium into the stomach, so that the obstruction may be visualized under the fluoroscope. Surgery affords the only hope of cure, and in the hands of well-trained operators the mortality is surprisingly low. Preoperative Care. The preoperative preparation of these tiny starved infants is fully as important as the actual operation. Unless the diagnosis is made promptly and the infant is in a rela- tively good state of nutrition and hydration, it is necessary to postpone surgery for a week or ten days. During this period strenuous efforts are made to improve the status of the infant's nutrition by means of parenteral therapy. Gastric lavage, one or more times daily, helps to reduce the size of the stomach, and occasionally will relieve the obstruction somewhat, permitting the ingestion of small amounts of nutritive fluid which may succeed in passing the constricted pylorus. Fredef-Ramstedt Pyloroplasty. The most successful and widely used procedure is the Fredet-Ramstedt pyloroplasty, named for the two surgeons who first described it. The operation may be performed under local anesthesia, but a light ether anesthesia is preferable because it is helpful to the surgeon iſ the infant can be prevented from crying or otherwise straining during the pro- cedure. The enlarged pyloric muscle is exposed through a small upper right abdominal incision, and an incision made which splits the muscle bundle parallel to the long axis of the lumen of the pylorus. Care is taken to make the incision only sufficiently deep to expose the submucous layer (submucosa), so that the actual lumen is not entered. There is thus no chance for leakage of stomach contents and for infection. The edges of the muscle bundle are gently spread apart, and nothing further need be done; the obstruction is relieved, the infant at once starts to gain and grow normally, and in later years pyloric function remains normal. 250 NURSING IN SURGERY OF THE ALIMENTARY TRACT Nursing Care. In preparing to take care of the baby following operation, it is advisable to have oxygen and an electric aspirator ready for use. Iſ the baby had general anesthesia, it is judicious to place the baby in a crib with the foot elevated; this helps to prevent aspiration in the event of vomiting. If no anesthesia was used, it is helpful to raise the head of the Crib one notch to pre- vent vomiting. In some clinics, the head is raised higher than this, necessitating some device to keep the infant in this position. Small sandbags placed under the arms prevent the baby from sliding down. Another means which has proven helpful is by placing the buttocks of the baby in a little hammock made of diapers which are secured to each side of the crib. Parenteral fluids are administered for the first twenty-four hours or until fluid intake by mouth is adequate. Fluids should be given slowly, which means between 8 to 15 drops per minute. Feedings are usually begun eight to twenty-four hours after operation. The general principle is to start with small amounts, increasing gradually. Iſ the baby vomits, the surgeon is notified. One method of feeding begins with a 4 cc. feeding eight to twelve hours after operation, with 4 cc. increments every two hours. As the volume increases to ordinary amounts, the interval between feeding is lengthened. One-half strength formula or breast milk is given; full strength is more difficult to digest be- cause the emptying time of the stomach is prolonged when a high ſat Content formula is administered. The baby is fed by eye dropper until amounts over 30 cc. are reached. Very little air is swallowed by this technic. After this, the baby should always be picked up to be fed from the bottle and the head of the bed is elevated for at least twenty minutes thereaſter. By the time the infant leaves the hospital, on approxi- mately the seventh postoperative day, he usually has been placed on a four hour feeding schedule. It is helpful when the mother is present to feed the baby in the hospital before discharge. To find out if she has any appre- hension or questions Concerning the care of the inſant is the responsibility of the nurse. It is not usual for a tiny baby to have such an operation and, therefore, the nurse should give explana- tions according to the needs. These needs are only discovered by Conversation, with interest directed to the care of the inſant. ULCERS OF THE STOMACH AND DUODENUM Acute or chronic ulceration of the stomach or duodenum is an exceedingly common lesion. It is of frequent occurrence in men NURSING IN GASTRIC SURGERY 251 of all ages, much less frequent in women, and rare in children. Despite much study over a period of many years, the cause re- mains unknown. Although ulcers of the stomach and duodenum (the so-called peptic ulcers) produce a variety of symptoms and signs due to differences in location, activity, and chronicity, there is one symptom that is so characteristic as to be pathognomonic. This symptom is hunger pain. It is a boring, severe type of pain felt commonly in the epigastrium, to one or the other side of the mid- line, and often radiating straight through to the back on the same side. This pain characteristically occurs when the stomach is empty, usually two to four hours after a meal, and is relieved by eating or by taking bicarbonate of soda. Many of the patients who have this kind of pain will volunteer the information that a glass of milk or other food or a dose of soda relieves the pain. Hunger pain is particularly common in the chronic form of the disease. tº Of the many patients who have ulcers, the largest proportion are a rather characteristic type: the tense, restless or irritable individuals, who are apt to be heavy tobacco consumers. No explanation of this observation has been advanced; there are plenty of restless people and chain smokers who do not have ulcers and, indeed, the existence of an ulcer is sufficient to render the most placid person irritable or to drive him to worse habits than Smoking. The acute ulcer may take many courses. One of these is acute perforation. As has been stated, the basis for the original ulcera- tion is not understood, but it is easy to see how the powerful gastric secretions can digest away the wall of the stomach once the break in continuity of the mucous membrane has been estab- lished. If the perforation occurs in a portion of the stomach, or duodenum that is anatomically in contact with another struc- ture, a localized inflammatory lesion is the result; but if the perforation takes place into the free peritoneal cavity an acute peritonitis is the result. Another and frequent course taken by an acute ulcer is erosion of a blood vessel in the wall of the stomach with consequent massive hemorrhage, or repeated hemorrhages. A third possibility is that the acute ulcer will progress very slowly, with much concomitant inflammation and scarring, re- sulting in pain, recurrent small hemorrhages, and deformity of the stomach or duodenum, often complicated by obstruction. A fourth possibility, and perhaps the commonest one, is that the acute ulcer will heal without having given rise to the serious com- 252 NURSING IN SURGERY OF THE ALIMENTARY TRACT plications just mentioned. Since this is so, the largest proportion of patients who have a peptic ulcer can be treated successfully by medical means and should not be operated upon. Many patients suffer from recurrences of their ulcer, however, and in Some the ulcer persists continuously as a chronic ulcer; the patients of this last group are the ones for whom surgery is most often necessary. Didgnosis of Peptic Ulcer Symptoms. Pain of the “hunger” type, epigastric distress with frequent sour eructation, or the vomiting of blood (hematemesis) are among the commoner symptoms which cause the patient to seek medical aid. In many instances the patient will have had similar symptoms months or years before. An occasional patient has an exsanguinating hemorrhage as the first symptom; such a patient may suddenly collapse on the street or elsewhere. Large amounts of blood may be passed per rectum unnoticed by the patient, or he may have noted the passage of a large tarry stool. Still other patients, especially those whose symptoms have not been sufficiently troublesome to cause them to seek medical ad- vice, may not come to the physician until late in the disease, at which time the chief complaint is likely to be vomiting with in- ability to retain enough food to maintain nutrition. Physical examination may reveal the signs of anemia if there has been re- peated loss of blood, or of starvation and dehydration if the patient has been vomiting; in many patients, however, no abnor- mal physical signs are to be found. Perforation. The perforation of a peptic ulcer into the perito- neal cavity is not difficult to diagnose. The abrupt onset of excruciating upper abdominal pain, followed quickly by gen- eralized abdominal pain, weakness, and discomfort in breathing, is accompanied by the physical signs of acute generalized perito- nitis, including rigidity of the abdominal wall, grunting respira- tion, acute tenderness, fever, leukocytosis, and shock. Gastric Acidity Test. Valuable information is gained from ex- amination of the secretory activity of the stomach. In nearly every normal person the gastric juice is slightly acid when fast- ing; following the stimulus of eating there is an increase in the amount of hydrochloric acid secreted. In the case of the patient with a peptic ulcer, however, there is nearly always a higher than normal concentration of acid in the fasting stomach, and after stimulation the acidity of the gastric juice increases rapidly. The usual procedure is to introduce a small tube into the stomach NURSING IN GASTRIC SURGERY 253 TABLE 2. Results of Gastric Analyses in Typical Patients (Expressed in Degrees of Free Hydrochloric Acid) FASTING AFTER HISTAMINE (UNITs) (UNITs) Normal . . . . . . . . . . . . . . . . 5 25 Peptic ulcer . . . . . . . . . . . . 20 70 Gastric cancer . . . . . . . . . . 0 0 early in the morning before the patient has eaten breakfast. A sample of gastric juice is withdrawn, but the tube is left in place. Gastric secretion is then stimulated by one of various methods, such as: (1) having the patient eat two slices of bread; (2) in- troducing a small quantity of alcohol through the tube; or (3) administering a small dose of histamine intramuscularly. Further samples of gastric juice are withdrawn at intervals; later these are analyzed for their acid content and a comparison with normal standards is thus obtained. It is customary to express gastric acidity in degrees which represent the equivalent of the number of cubic centimeters of one-tenth normal hydrochloric acid per 100 cc. of gastric juice. The samples are also examined for the presence of blood. Delayed emptying of the stomach may be suspected if the sample contains many bacteria or particles of undigested food. Roentgenography. Easily the most important and valuable diagnostic procedure, however, is roentgenography. A competent roentgenologist, observing the stomach and duodenum under the fluoroscope as the patient swallows a mixture containing barium sulfate, can often see the ulcer. Even when the ulcer is in such a position as to be obscured, it can be diagnosed by the accom- panying deformity of the stomach or by the associated alteration in the motility of the gastric muscles. It is important that the patient be properly prepared for fluoroscopy. The stomach should be empty; breakfast must therefore be deferred until after the examination. An enema should be given so as to eliminate as much of the gas in the large intestine as possible. In certain persons the stomach tone and motility are greater than average although no ulcer is present, and in these the hypermotility seen in the first examination may be suppressed or abolished by a few days of rest and by the administration of tincture of bella- donna (atropine). Roentgenography also affords a means of observing the effect of therapy, since examinations carried out at intervals shows whether the ulcer is healing or not. 254 NURSING IN SURGERY OF THE ALIMENTARY TRACT FIGURE 73. X-ray film showing a duodenal ulcer outlined by barium. Arrow points to crater of ulcer. Benzidine Test. There is usually blood in the stool of the ulcer patient, and the nature and amount of this blood depend upon the amount and rate of bleeding and upon the motility of the intestinal tract. Following a large hemorrhage there is usually gross blood in the stool, although it is very dark red or black as a result of digestion while passing through the tract. Small amounts of blood may be detected only by chemical test (benzidine), for the cells are digested. Since meat eaten by the patient can give a falsely positive test, a positive benzidine test on the stool is of value only if the patient has been on a meat-free diet for three or four days previously. Gastroscopy. A relatively new diagnostic method is the direct observation of the stomach mucosa through the gastroscope. Since it is not yet possible to examine the pyloric portion because of the limitations of the instrument, the majority of gastric ulcers cannot be visualized. Some ulcers may be seen, however, and the experts in this field believe that they can detect in many cases an NURSING IN GASTRIC SURGERY 255 2/ gaseº- FIGURE 74. Examination of the stomach through the gastroscope. Note posi tion of patient. FIGURE 75. Set-up for gastroscopy. alteration in the appearance of the mucosa which indicates an ulcer that is beyond the view of the gastroscope. Nursing Care. It is desirable that the patient be instructed not to eat or drink anything for at least eight hours before gas- troscopy. When the patient is known to have retention in his stomach, a lavage is done to prevent regurgitation of fluids with the danger of subsequent aspiration into the lungs. The general preparation is similar to that described for bronchoscopy on page 115. After treatment, the patient should be made comfortable and should be instructed not to swallow anything from two to four hours. The hazard of aspirating food or fluid into the trachea should be carefully explained. This is especially important for the outpatient who leaves the hospital before the anesthesia has worn off. He should also be told that a sore throat is not unusual 256 NURSING IN SURGERY OF THE ALIMENTARY TRACT but this will be transitory. A rest period is advisable, for most patients find this procedure exhausting. The length of time will depend upon the reaction of the individual. Trecitment of Peptic Ulcer The greater portion of all ulcers of the stomach and duodenum will respond to and may be cured by a program of treatment that includes rest, special diet, and medication. Sippy, an American physician, was responsible for the popularization of this regimen, and his standard diets for the treatment of ulcers, though now somewhat modified to meet the requirements of modern knowl- edge of dietary deficiencies, are still commonly used. Rest in bed, freedom from business cares or other worries, and abstention from tobacco and alcoholic beverages are enforced in the first period of the treatment. The most important principles to be observed in the diet are that the feedings shall be small and fre- quent, served at regular short intervals, and that the diet should contain no mechanically harsh material and should lack none of the essential vitamins. Medication includes an antispasmodic, usually tincture of belladonna, mild sedatives if the patient is restless, and alkali to neutralize the high acidity of the gastric juice. The carbonates of bismuth, calcium, and sodium were most commonly used until recently; at present it seems that the colloidal suspension of the mildly alkaline aluminum hydroxide, administered at frequent intervals by mouth, or continually by means of an inlying tube, is a more effective agent in Combating the hyperacidity. Another extremely useful medication is Ban- thine, one of a group of drugs which have the ability to block the action of the vagus nerve. This drug can be tolerated by most individuals and, if taken regularly, will reduce secretion of hydrochloric acid to the vanishing point. If therapy is successful, the patient's symptoms disappear, and the ulcer can be seen to be healing when studied by roentgenog- raphy. Under these conditions the patient is permitted very grad- ually to resume his former activities and to return to a full, ordinary diet. The medication is discontinued. This whole pro- gram, however, must be spread over a period of three to six months or longer. Operative Trecitment of Complications It is generally accepted that surgical treatment for peptic ulcer is indicated when symptoms persist despite thorough medical -stºpy-pºrºzºr- *** -ºr- The basic feeding is three ounces (90 cc.) of milk (half cream), given every hour from 6 a.m. to 10 p.m. inclusive, and on any hour during the night if the patient is awake. The basic feeding is supplemented as follows: DAY 7 A.M. 10 A.M. 1 P.M. 4 P.M. 6 P.M. 9 P.M. 2 3 oz. sieved cereal 1 soft-cooked egg 2 tsp. sugar 2 saltines 3 1 soft-cooked egg custard 3 oz. sieved cereal 2 saltines 2 tsp. sugar 4 3 oz. sieved cereal custard milk toast (1 slice) cream soup 2 tsp. sugar 1 sq. butter 1 soft-cooked egg 4 saltines 5 3 oz. sieved cereal milk toast (1 slice) 1 soft-cooked egg custard Cream soup 4 cookies 2 tsp. sugar 1 sq. butter 2 saltines 3 oz. steamed rice 1 sq. butter 6 1 soft-cooked egg 3 oz. sieved cereal cream soup 3 oz. sieved cereal 1 soft-cooked egg dessert 4 saltines 2 tsp. sugar 2 saltines 2 tsp. sugar 2 saltines 7 1 soft-cooked egg 1 oz. cottage cheese 3 oz. sieved cereal dessert cream soup 4 cookies 1 slice toast 4 saltines 2 tsp. sugar - 1 soft-cooked egg 1 sq. butter 1% oz. orange juice 1 slice toast 1 sq. butter 8–14 3 oz. sieved cereal dessert % c. mashed potatoes 2 saltines 1 soft-cooked egg dessert 2 tsp. sugar 1% oz. orange juice 1 sq. butter 1 thsp. jelly 3 oz. steamed rice 1 soft-cooked egg dessert 1 slice toast 1 slice toast 1 sq. butter 1 sq. butter 14–21 Soft diet without meat, including intermediate nourishment three times a day of 6 oz. of milk (half cream) with crackers. Hourly milk is discontinued. 21–28 Same as on days 14–21 with addition of ground meat. Meulengracht Diet 1. Amount of food. . . . . . . . . . . . . . . . . . ad libitum, especially milk (no coffee or tea until ordered by physician) 2. Intermediate feeding, 10 a.m., 3 p.m., 9 p.m., of 8 oz. of milk (half cream) 3. At least three soft foods to be included in each meal The Meulengracht diet is a soft diet with the following modifications: 4. Liver to be given at least twice a week § 258 NURSING IN SURGERY OF THE ALIMENTARY TRACT treatment, or when complications arise that are not amenable to medical therapy. It is not always easy to differentiate between a gastric ulcer and gastric cancer; furthermore, a cancer not infre- quently arises from an ulcer. For these reasons it is wise to operate upon any gastric ulcer that does not show evidence of healing aſter a proper course of medical treatment. This indica- tion does not apply to duodenal ulcers, because cancer of the duodenum is an extremely rare disease. Perforation. The most dramatic Complication is the Sudden perforation of the wall of the stomach or duodenum into the free peritoneal cavity. Well recognized as an urgent surgical emer- gency, a perforated peptic ulcer is best treated by early lapa- rotomy with simple closure of the perforation by means of su- tures. This treatment is highly successful: the mortality is low if the procedure is carried out within the first few hours after perforation has occurred; on the other hand, it rises very rapidly iſ more than eighteen hours has elapsed, and few patients are saved iſ treatment is not undertaken within the first twenty-four hours after perſoration. That is because a rapidly fulminating bacterial peritonitis develops on top of the highly irritating chemical peritonitis which results from the discharge of the gastric juice into the peritoneal cavity. Hemorrhage. Another Common Complication of peptic ulcer which may require emergency treatment is sudden massive hem- orrhage. There is some bleeding with all peptic ulcers but this usually subsides as the ulcer heals. In the more chronic type of ulcer, however, particularly when there is considerable scar tissue in the base of the ulcer, a large vessel may become eroded. From such a source an exsanguinating hemorrhage sometimes occurs because the scar tissue prevents the natural retraction and contraction of the walls of the opened blood vessel. Conservative therapy, including elevation of the foot of the bed, quiet, the administration of morphine, and an ice cap to the abdomen, should be tried first; nothing is permitted by mouth, and both transfusions and intravenous fluids are given with extreme caution and slowness, so as to maintain the blood pres- sure at as low a level as is saſe in order to facilitate clotting of the blood at the bleeding point. If the bleeding persists, or iſ it occurs again after a short interval, operation should be under- taken with the purpose of exposing the bleeding point and con- trolling the hemorrhage. Surgical treatment should be carried NURSING IN GASTRIC SURGERY 259 out earlier in older patients because they do not withstand the acute loss of blood so well as younger persons. Large amounts of blood should be on hand to give to the patient during and after the operation. Lumen Obstruction. Some degree of obstruction of the pyloric lumen is a frequent complication of peptic ulcer. Sometimes the obstruction is caused by the edema which is a part of the in- flammatory reaction about the acute ulcer, and in such cases the blockage usually is relieved by conservative treatment. When the lumen in the pyloric region is narrowed as a result of the forma- tion of scar tissue, however, the obstruction persists and surgical intervention is necessary. Equally important as the operation is the preoperative preparation, for many of these patients suffer from extreme malnutrition and dehydration which must be treated before operation is undertaken. Pain. The persistence of severe pain despite medical therapy is another indication for operation. In such instances it is Com- mon to find that the ulcer is a penetrating one, often invading the pancreas. If possible, such an ulcer should be eradicated. NEOPLASMS OF THE STOMACH AND DUODENUM Benign tumors of the stomach and duodenum are rare. Occa- sionally a polyp (epithelial papilloma) of the mucosa develops, and makes its presence known by bleeding. Simple excision is curative. Benign fibroma is sometimes found in the wall of the stomach, but is usually not productive of symptoms. Carcinoma of the stomach, on the other hand, is one of the commonest forms of human Cancer, and is one in which treat- ment, up to the present time, has proved least satisfactory. One of the many puzzling features about it is the difference in its rate of occurrence in males and in females. If one excepts all ſorms of skin cancer, gastric cancer is the Commonest form of cancer in men, but it is far less often observed in women. The ratio is about five to one. Another remarkable fact is the rarity of car- cinoma arising from the adjacent and Contiguous duodenal mucosa. Probably the worst feature of cancer of the stomach is the absence of symptoms early in the disease, so that the great majority of the victims of this malignant tumor have no warning that might lead them to seek medical aid while the tumor is still in the early, curable stage. It is a disease of middle age and be. yond, being fairly uncommon in those under 40 years of age. 260 NURSING IN SURGERY OF THE ALIMENTARY TRACT Didgnosis of Carcinoma of the Stomach Until a better method of treatment is evolved, only those pa- tients in whom the tumor has not spread beyond the walls of the stomach can be cured; thus early diagnosis is imperative. The occurrence in men over 40 of any vague complaint which might be reſerable to the stomach should be followed by a thor- ough investigation and by careful observation thereafter iſ the diagnostic studies are inconclusive. Symptoms. One of the Commonest early Symptoms is a Change in the individual's appetite, either a gradual loss of appetite (anorexia) or a distaste for certain foods that formerly were eaten with enjoyment. There may be some upper abdominal discomfort which the patient refers to as “indigestion,” or a heavy feeling, or a pressing weight. Eventually, as the tumor grows and metas- tasizes, the afflicted person loses weight and strength and becomes severely anemic, and symptoms of obstruction appear, with re- gurgitation of undigested food. Actual pain is a very late Symp- tom. In an occasional case, when the tumor is situated at or very near the pylorus, obstruction occurs early in the disease, so that the patient is forced to seek medical advice while there is still a chance for cure. Hemorrhage is the rule, although the bleeding is usually slight until the final stages. Gastroscopy and Roentgenography. There are no diagnostic physical signs of gastric cancer while it is still in the curable stage; by the time the physician can palpate the tumor mass through the abdominal wall, cure is unlikely. Accurate early diagnosis is based upon gastroscopy and roentgenography. By these means the tumor, or its deforming effect on the gastric out- line and motility, is observed. Gastric Acidity. Reduction in the acidity of the gastric juice is a characteristic phenomenon. Commonly there is complete ab- sence of free acid (achlorhydria); this is in striking contrast to the high acidity found in peptic ulcer (Table 2, p. 253), but it must be borne in mind that exceptions are frequent. Trecitment of Ccarcinomc of the Stomcich Cure may be accomplished surgically by complete removal of the growth; this involves the removal of a part or all of the stomach. Since it is usually not possible to tell before operation whether or not the tumor has spread beyond the confines of the NURSING IN GASTRIC SURGERY 261 stomach, many patients are found at operation to have an incur- able lesion. For some of these, procedures are carried out which are palliative though not curative, such as removing some of the tumor-bearing stomach to prevent further hemorrhage, and short- circuiting procedures to relieve obstruction. These palliative operations make liſe more bearable for the victims, and in some instances add an appreciable period of comfort and usefulness to the liſe of the patient. Therapy by means of radium or by deep roentgen irradiation has not been successful. The rate of permanent cure of patients who have cancer of the stomach is still very low, probably less than 10 per cent for the country as a whole. While a continuous effort is being made to find a better method of treatment, the main hope, as in most other forms of cancer, still lies in early diagnosis and prompt treatment. OPERATIONS ON THE STOMACH AND DUODENUM Preoperative Care. It must be reemphasized that many of the patients who need operation have, as a preoperative Complication of their illness, either dehydration or starvation or both to some degree. The parenteral methods of treating these conditions have been discussed in Chapter 5, page 49. Another preparatory measure of great importance is gastric suction drainage (p. 243). In patients who have had pyloric obstruction the stomach is likely to be much enlarged, with edema and weakening of the stomach wall as a consequence of the prolonged dilatation, so that the tissues are in poor condition for healing. Finally, it is immensely important that the stomach be emptied immediately before operation, so as to prevent the spilling of a large amount of infective material into the peritoneal cavity if it should prove necessary to open the stomach during operation. This is usually accomplished by placing a Levin tube in the stomach. The pa- tient should be prepared for what is to happen in a manner that he will understand. He should be told that it is essential for him to have an empty stomach before operation and that the tube will remain in the stomach for a short time after opera- tion. Understanding what will be done to insure the best care not only enlists the cooperation of the patient but also gives him a sense of security. Before the tube is inserted into the nostril, the tip may be dipped into isotonic saline solution to provide for easy passage. 262 NURSING IN SURGERY OF THE ALIMENTARY TRACT e * * * |º gº:W | FIGURE 76. Gastrostomy. After the tube is inserted, the stomach contents are then with- drawn either with a syringe or by attaching the tube to suction equal to 2 to 5 feet of water. The tube should be secured to the cheek and/or forehead with adhesive tape, so that motion will not be transmitted to the sensitive nasal mucosa. Gastrostomy All operative procedures upon the stomach and duodenum come under the heading of laparotomies, so that all that has been said (p. 224) is applicable. Occasionally it is necessary to open the stomach for the purpose of removing a foreign body; simple opening of the stomach, followed by closure, is called gastrotomy. To be differentiated from this last is gastrostomy, already men- tioned in connection with disease of the esophagus. Gastrostomy has for its purpose the creation of a permanent opening through the abdominal wall into the lumen of the stomach so that the patient may be fed. Through a small upper left abdominal in- cision the anterior wall of the stomach is exposed, drawn ſor- ward, and sutured to the anterior abdominal wall about the in- cision. A small opening is made into the lumen of the stomach through which a catheter is introduced; this opening is sutured tightly about the catheter so that no leakage will occur, and the catheter is firmly fixed by suture or adhesive tape to the ab- dominal wall so that it will not slip out. This operation may be easily performed under local anesthesia, a considerable advan- tage when dealing with very ill patients. NURSING IN GASTRIC SURGERY 263 Nursing Care. Within a very few hours the peritoneum of the stomach and that of the abdominal wall become adherent and sufficiently leakage-proof so that water and nutritive fluids may be cautiously introduced through the tube; aſter seventy-two hours it is usually possible to ſeed the patient an adequate diet through the tube. An adequate formula ſor tube feeding has been previously listed on page 50. The technic for instilling the formula and the care of the surrounding wound have also been described (p. 216). Healing of the tract is complete after ten days, and it is then possible to remove and replace the tube as desired for cleaning purposes. If, however, the tube is not replaced immediately, there may be contraction or even complete healing of the Opening; but as a rule it is necessary to operate in order to close the gas- trostomy when it is no longer needed. Gcastroenterosfomy Preoperative Care. The importance of careful preoperative preparation in this operation is obvious, for these patients who have had pyloric obstruction are starved and dehydrated, and have large, atonic, and bacteria-laden stomachs. Operative Technic. The short-circuiting operation to relieve pyloric obstruction is gastroenterostomy, meaning, literally, the construction of an opening between the stomach and the intes- tine. There are two ways of doing this: in one, the posterior gastroenterostomy, the opening (amastomosis) is made between the posterior wall of the stomach and the first loop of the je- junum, this loop being brought up adjacent to the stomach through an opening which is made in the mesentery of the trans- verse colon, so that the loop of jejunum passes behind the trans- verse colon. This is the most satisfactory method, but sometimes it cannot be performed. The other method is the anterior gastro- enterostomy, in which the loop of jejunum is brought up over the front of the transverse colon, and the anastomosis is per- formed between the jejunum and the anterior wall of the stom- ach. In either case, stomach contents may then pass through this new opening directly into the jejunum, by-passing the pylorus and the duodenum, as shown in Figure 77. Under modern condi- tions this operation is performed with very little risk to life, and, iſ used in properly selected patients, the results are highly suc- Cessful. In most clinics inhalation anesthesia is commonly used for this procedure. 264 NURSING IN SURGERY OF THE ALIMENTARY TRACT \ ‘. ../** " I tº: * ~ *. N sº N º FIGURE 77. Gastroenterostomy. A, Anterior (antecolic); B, posterior (rctrocolic). Nursing Care. The preparation, in general, of patients for surgery of the stomach is adequate hydration and withdrawal of the contents through a Levin tube connected to suction. Some- times a lavage is carried out, iſ there is evidence of pyloric ob- struction. Careful measurement of intake and output cannot be overemphasized. The character of the drainage should also be observed and charted. The general aspects of care necessary ſor all patients who anticipate surgery as described previously should be carried out to insure the optimum physical and, mental Com- ſort. After operation these patients are treated essentially the same as any laparotomy patients, but with special attention to the Levin tube siphonage and diet. The Levin tube is usually con- nected to suction for about twenty-ſour hours to keep the stom- ach empty and to promote healing. The drainage should be ob- served frequently to determine the color, consistency and amount. The drainage may be bright red for a half hour or so immediately after surgery, but thereafter it should be dark red or brown. If it continues to be bright red, the surgeon should be told because it signifies active bleeding. The drainage should be measured and recorded at least every twelve hours. The sur- geon usually orders irrigations of the tube which may be carried out as described on page 245. * The diet aſter gastroenterostomy or resection depends upon the patient and surgeon. Usually, aſter the tube is removed, tap water is given in small amounts (30 cc.) every hour for the first day, then a liquid diet increased to 60 or 90 cc. is usually offered. NURSING IN GASTRIC SURGERY 265 Frequently the patient may progress more rapidly than this, up to soft diet in limited portions on the fourth day. However, each patient is given ſood according to his tolerance, preventing a set rule for a dietary regimen. It is important to try to supply adequate fluids and solid food but not to urge eating or drinking iſ there is a complaint of ſullness. The soft diet given in six small ſeedings is gradually increased to a normal diet in six small ſeedings. In learning about his diet, the patient should be encouraged to assume responsibility for the planning of his diet. The factors which should be emphasized as the nurse plans with him are the importance of adequate fluid and food intake and the mainte- nance of weight. In the postoperative ſeeding schedule complete withholding of fluid is unnecessary because one can be sure that there will be fluid in the stomach anyway, since the gastric mucosa is going to continue to secrete just as before operation; and if this fluid does not leak through the new suture line, it is unlikely that a little water given by mouth will do so. On the other hand, it is en- tirely conceivable that a large amount of fluid might, by its very weight, cause tearing and consequent leakage; it is wise, there- fore, to limit the amount of fluid or other material in the stomach to small, safe amounts until the suture line is healed. This limita- tion applies not only to ſluid given by mouth, but also to fluid which might accumulate in the stomach as the result of gastric secretion plus some failure of the new anastomosis to function well, and it is thus extremely important to observe the patient careſully, so that the stomach can be aspirated at any time that it shows a tendency to fill up. Vomiting, and especially the repeated regurgitation of small amounts of stomach contents, should lead at Once to the sus- picion of an increasing accumulation of fluid or gas, or both, in the stomach. Diagnosis of this complication is confirmed by per- cussion of the stomach, and by the aspiration of a large quantity of ſluid upon the passage of a stomach tube, and should be fol- lowed immediately by the introduction of an inlying tube to which is applied the Wangensteen continuous suction apparatus. This complication is not at all uncommon after gastroen- terostomy, particularly at first when the immediate swelling of the recently incised tissues is present; many surgeons prefer to introduce the inlying tube during or directly after operation. 266 NURSING IN SURGERY OF THE ALIMENTARY TRACT Stump of St. duod &nugm ump of duodenum, Jejunum FIGURE 78. A, Partial gastrectomy (Polya antecolic end-to-side gastrojejunos tomy). B, Total gastrectomy. Vogectomy Since the secretion in the stomach of hydrochloric acid is controlled by impulses traveling down the vagus nerves from the brain, it is possible to reduce remarkably the secretion of acid by dividing the vagus nerves (vagectomy). Both nerves must be cut; this can be done through an incision in the chest or through an abdominal incision. Because cutting the nerves in- terferes with the motility of the stomach, delaying the emptying, it has been found best to combine gastroenterostomy with va- gectomy in the treatment of duodenal ulcers. The postoperative care of a patient who has had this pro cedure is the same as aſter gastroenterostomy. It may be necessary to employ suction drainage longer than when vagectomy is not done, and Urecholine may be used to improve gastric motility and muscle tone. Gdstrectomy The term gastrectomy is used to designate the operations in which some or all of the stomach is removed. In a partial gas- trectomy a portion of the stomach is removed, in a subtotal gastrectomy nearly all of the stomach is removed, and in a total gastrectomy the entire stomach is removed. Gastrectomy, although first successfully performed more than half a century ago, until quite recently has been associated with a ſormidable mortality. Modern methods of building up the pa- tient before operation, and modern knowledge of diet after NURSING IN GASTRIC SURGERY 267 operation for the patient who has no stomach left, together with modern technical skill at the operating table, are now successful in bringing through five out of every six patients who undergo removal of the entire stomach. Furthermore, if a small portion of the stomach can be spared, the mortality is scarcely higher now than that after simple gastroenterostomy. In partial gastrectomy the feeding plan is the same as that in gastroenterostomy (p. 264). A commonly used regimen for the feeding of the total gastrectomy patient is as follows: DAY HOUR A MOUNT FOOD 1–4 Nothing by mouth 5 6 a.m.-10 p.m. 15 cc. Tap water every hour 6 6 a.m.-10 p.m. 30 cc. Tap water every hour 7 6 a.m.-10 p.m. 45 cc. Tap water every hour 8 6 a.m.-10 p.m. 60 cc. Tap water alternating with broth every hour three times a day 9 6 a.m.-10 p.m. 75 cc. Tap water alternating with broth as every hour desired 10 6 a.m.-10 p.m. 90 cc. Tap water alternating with broth, every hour fruit juice, and milk 11 6 a.m.-10 p.m. 120 cc. Tap water alternating with broth, every hour fruit juice, and milk 12 and thereafter 8 a.m., 10 a.m., Fluids Soft diet six in small feedings 12 N., 3 p.m., ad lib. 6 p.m., 8 p.m. The diet is usually increased to six small feedings as outlined and remains so in the majority of cases. When this regimen is to begin, it is necessary to consider the personality of the patient in order to select the type of diet. If he is one who has good teeth, is careful to chew his food and eats fairly slowly, a regularly prepared diet, high in calories, seems to be tolerated without un- toward effects. However, if the patient has poor teeth and/or eats rapidly, it is advisable that he eat a finely chopped and soft tex- ture diet. A fair appetite is usual, but a small amount of food satis- fies and the slight discomfort which may follow causes him to limit his intake. His weight may be maintained with good effort but he will not get fat after a total gastrectomy. Discomfort after eating may be relieved or averted if the patient lies down for a 268 NURSING IN SURGERY OF THE ALIMENTARY TRACT few minutes aſter each meal. Cold foods should be avoided be- cause they tend to bring about distress. Untoward symptoms ſol- lowing a meal include excessive ſullness, weakness, nausea, pal- pitation and Sweating. The nurse should begin explaining the essentials of good nutrition, the components of his diet, and their preparation when the patient is well enough to be interested. In order to make this applicable to daily living, the nurse must find out what the patient likes and dislikes. It is of little value to make out a menu and discuss preparation of foods which are not acceptable to the patient. Much explanation on the part of the nurse may Cause resistance; it is better to try to encourage the patient to assume responsibility. Progress is evidenced by questions, and later by assurance that he can cope with this important aspect of self-care. The patient will be requested to return to his surgeon for check-ups. It must be kept in mind that the majority of these patients were operated upon because they had cancer of the stomach. The nurse should try to do all she can to make him understand that his surgeon will wish him to return even though he feels perſectly well. Outcome. Many persons, following removal of a large portion of their stomach may, after a due period of Convalescence, resume a normal life, including their former eating habits. This is not true, however, of those patients who have had total gastrectomy; in these the ingested food passes directly from the esopha- gus into the jejunum, and is not subjected to any of the digestive processes normally encountered in the stomach. Furthermore, the small intestine cannot receive the quantity at one ſeeding that the stomach can. For these reasons, the gastrectomy patient must necessarily eat Small amounts, must eat Oſten, and must eat foods which are predigested or which do not require much processing in order to become assimilable. The removal of the stomach also affects the proper formation of the red blood cells, so that anemia similar to primary anemia develops unless the necessary factors are supplied to the patient aſterward. If, however, only a small portion of the stomach has been removed, all these elaborate precautions are unnecessary, ſor such a patient needs only the same postoperative care as that afforded the patient who has had a gastroenterostomy, and will, like the latter, eventually return to a nearly normal mode of existence. NURSING IN GASTRIC SURGERY 269 Complications of Gastroenterostomy cºnd Gastrectomy Unfortunately there are some special complications of gastro- enterostomy and gastrectomy which occur with sufficient fre- quency to warrant further consideration. Marginal Ulcer. First and commonest of these is the so-called marginal ulcer. This is an ulcer which develops along the line of junction between the gastric and jejunal mucous membranes at the site of the gastroenterostomy, and which is due, presumably, to the action of the acid gastric juice upon the jejunal mucosa, which ordinarily is exposed only to alkaline secretions. Why this type of ulcer should occur in only a small fraction of all such anastomoses is not known. The symptoms are much like those of peptic ulcer, and the complications are likewise similar. Perfora- tion and peritonitis may occur, as also may perforation into the transverse Colon, with resulting gastrocolic fistula. Medical treat- ment is unsatisfactory; surgical treatment is difficult and dan- gerous and is followed by a high incidence of recurrences. Some surgeons recommend vagectomy as the best treatment for mar- ginal ulcer. It is intriguing, however, to note that marginal ulcer occurs as a complication of the combined vagectomy and gastroenterostomy procedure. Duodenal Fistula. A less Common Complication of gastrectomy is leakage of the closed stump of the duodenum, with formation —if the patient survives—of a duodenal fistula. This complication also follows certain operations upon the common biliary duct, particularly when reconstruction, or reimplantation of the duct into the duodenum is attempted. It is a dangerous complication because: (1) there is excessive loss of fluid and electrolytes with Consequent imbalance and loss of enzymes necessary for ade- quate digestion; and (2) the powerful secretions rapidly digest away the tissues of the abdominal wall and wound. Nursing Care. The vital signs are those associated with a very ill patient. A fever, rapid pulse, low blood pressure, great pros- tration and severe abdominal pain are signs and symptoms that the nurse may observe in a patient with duodenal leakage. The fluid lost through the fistula is comprised of gastric, duodenal, pancreatic and biliary secretions; up to 7 liters a day may be lost through this opening even when no fluids are taken by mouth. The maintenance of fluid, electrolyte and nutritional balance necessitates strenuous intravenous therapy. In addition, large amounts of vitamins are also given to aid healing. It is not uncommon for the patient to receive over 5000 cc. of intravenous 270 NURSING IN SURGERY OF THE ALIMENTARY TRACT Suction tubø. SKin: linz . Fluid FIGURE 79. Sump drain. The outer tube holds the tissues of the wound away from the suction tube. fluid in a twenty-ſour hour period. It is desirable to achieve a urinary output of between 1500 and 2000 cc. Careful and prompt recording of all intake and output permits accurate appraisal of the therapy. The nurse should also observe the flow of the in- travenous fluids frequently to maintain the rate desired. Usually no more than 45 drops per minute are ordered; this permits utilization of proteins and prevents fever, vomiting and overflow through the kidneys. The surgeon frequently orders the collected fistula drainage to be re-fed when the patient has an inlying stomach tube. When this is not done, bile salts are given. Vitamin intake during the time of copious drainage consists of ascorbic acid, 1000 mg.; thiamine, 50 mg.; riboflavin, 50 mg.; nicotinic acid, 500 mg.; and liver extract, 2 cc. daily. Vitamin K is given when there is hypoprothrombinemia, or it is sometimes given to prevent it. The very active and abundant digestive ferments ſound in the upper portion of the gastrointestinal tract cause rapid excoria- tion of the skin as they seep over the abdominal wall. Within a few hours after the secretions flow out of the fistula, the skin is digested; it appears fiery red and oozes plasma similar to skin which has been burned. The ingredient most responsible for this is trypsin from the pancreas. NURSING IN GASTRIC SURGERY 27] Various methods have been devised to prevent the contact of secretions with the skin. One method of protecting the skin from secretions is to employ suction with a sump drain in the fistula (Fig. 79). The bedclothes are held off the area by a cradle which is placed over the patient. In addition, medications may be or- dered to be placed on the skin around the tube where the in- evitable seepage occurs. Ten per cent tannic acid, Kaolin, and aluminum hydroxide gel are preparations which have been used to neutralize the secretions. Also sponges soaked in beef extract or egg white have been placed around the tube in an attempt to divert the trypsin. Ointments seem to be of little value because the secretions tend to burrow through or seep under them. Frequent cleansing of the entire area is important and it has been observed that when this is done every hour, followed by re- application of whatever medication is ordered, digestion of the skin can be kept at a minimum. Sponging the area with aqueous benzalkonium chloride solution is satisfactory for cleansing the area; at times plain castile soap and water are used. Another method, used less frequently, consists of placing the patient on a Bradford frame in the prone position. The stream of secretions may then be collected in a basin. This, however, seems rather uncomfortable for the patient and prevents frequent turning, but is applicable when other means are not available. As the patient improves, it is often possible to get him to do his own cleansing by Conveniently arranging a tray with neces- sary supplies. The time that such a suggestion can be made de- pends entirely on the individual patient, but rarely does he feel well enough for a week or ten days after the discovery of the fistula. Convalescent care following such an episode is regulated upon the individual needs of the patient. Sometimes it is followed by an operation to close the fistula, but usually the fistula closes Spontaneously. SUMMARY Benign ulcer and Carcinoma are the common lesions of the stomach; ulcer frequently occurs in the duodenum. Surgery is performed for the serious complications of ulcer, and for can- cer. Operative mortality is kept low by proper hydration of pa- tients and drainage of the stomach before and after operation. The patient's well-being after operation depends largely upon how successfully he can maintain his nutrition. 272 NURSING IN SURGERY OF THE ALIMENTARY TRACT VOCABULARY REVIEW pyloroplasty sump drain marginal ulcer gastroscope gastroenterostomy duodenal ſistula vagectomy gastrectomy trypsin hyperacidity SUGGESTED READING 1. Albright, Hollis L., and Leonard, Field C.: Duodenal Fistula–Problems in Management. Ann. Surg., 132:49–63 (July) 1950. 2. Dragstedt, Lester: Gastric Vagotomy. Am. J. Nursing, 48:278-281 (May) 1948. 3. Fletcher, Archibald G.: The Present Status of Total Gastrectomy in the Treatment of Gastric Cancer. Surgery, 30:403-433 (August) 1951. 4. Grimes, Orville H., Bell, H. Glenn, and Olney, Mary B.: Congenital Hyper trophic Pyloric Stenosis. J. Pediatrics, 37:522–529 (October) 1950. 5. Heger, Catherine: Surgical Nursing Care of Patients with Duodenal Ulcer. Am. J. Nursing, 52:861–862 (July) 1952. 6. Krause, Marie V.: Nutrition and Diet Therapy. Philadelphia, W. B. Saunders Co., 1952, pp. 164–168. 7. Palumbo, Louis T.: Surgical Treatment of Duodenal Ulcer. Am. J. Nursing, 52:857–860 (July) 1952. 8. Scott, H. W., Jr., and Longmire, W. P., Jr.: Total Gastrectomy; Report of 63 Cases. Surgery, 26:488–498 (September) 1949. 9. Wilson, Helen A.: Nursing Care in Gastric Vagotomy, Am. J. Nursing, 48: 282 (May) 1948. CHAPTER 25 Surgery of the Liver, Biliary Tract, and Pancreas Anatomy and Physiology. The liver is the largest and heaviest organ in the body, and the multiplicity of its functions is even now not completely understood. From the standpoint of the surgeon, the most important function of the liver is the secre- tion of the bile, which is, among other things, essential to proper digestion. The bile is collected in the liver into the vast system of biliary ducts which finally drain into the main biliary ducts of the right and left lobes of the liver. These unite into a com- SURGERY OF LIVER, BILIARY TRACT, PANCREAS 273 mon hepatic duct just at the hilum of the liver. A short distance below this junction a smaller duct joins the hepatic duct. This is the cystic duct, and it leads into the gallbladder, a pear-shaped, saclike organ situated along the posterior inferior margin of the right lobe of the liver. The gallbladder has a double function, serving both as a reser- voir for bile and as a concentrating mechanism, for some of the water is absorbed, so that the bile which remains ſor a time in the gallbladder becomes more concentrated than that secreted by the liver. The secretion of bile is continuous, but the rate may be increased by certain stimuli, including the eating of a meal, particularly one high in fats, and by certain drugs such as mag- nesium sulfate. These stimuli, in addition to increasing the rate of secretion of the bile, cause the emptying of the bile from the gallbladder. Bile passes down the cystic and hepatic ducts into their common prolongation, known as the common biliary duct, which enters the posterior wall of the duodenum, adjacent to the head of the pancreas, through the ampulla of Vater. Just before opening into the lumen of the duodenum, the common duct is joined by the main pancreatic duct, so that the bile and the pancreatic juice enter the duodenum together. This is im- portant, for, although there are usually accessory openings of other little pancreatic ducts into the duodenum, an obstruction to the opening in the ampulla of Vater blocks the passage of all of the bile and most of the pancreatic juice, preventing these most important digestive juices from reaching the food upon which they are supposed to act. The pancreas (sweetbread) is a fish-shaped organ that lies behind the peritoneum, directly back of the duodenum, lower border of the stomach, and transverse colon. It serves both as a gland of digestion, secreting the pancreatic juice into the duo- denum, and as an endocrine gland, the pancreatic islands of Langerhans secreting insulin directly into the blood stream. To the left, just lateral to the tail of the pancreas, lies the spleen. This organ, although anatomically in the closest of rela- tions to the other organs of digestion, plays no known role in the function of the alimentary tract. The anatomic location and relationships of these organs is best appreciated by studying Figure 72. Note that the arteries which supply the liver, the spleen, the pancreas, the stomach, and the duodenum are all derived from the same branch of the 274 NURSING IN SURGERY OF THE ALIMENTARY TRACT aorta, and that the blood from all of these organs is carried to the liver through the tributary branches of the portal vein. JAUNDHCE This condition, in which the skin becomes yellow, is so Com- mon that almost everyone knows something about it. In order to appreciate the significance of jaundice, however, the student must know the ſacts about the remarkable cycle in which the blood and bile pigments are interrelated. When a red blood cell becomes too old to function efficiently it is removed ſrom the circulating blood by the reticuloendothelial cells of the body which are in the spleen, liver and bone marrow. The worn-out cell is taken apart, and the hemoglobin, that brilliant red chemical compound which has the ability to transport oxygen, is changed into the bile pigments by the reticuloendothelial cells. The bile pigments travel in the circulating blood to the liver, where they are taken out of the blood by the liver cells. The bile pigments are called bilirubin and biliverdin, and are re- sponsible for the yellowish green color of the bile. The bile passes from the liver, by way of the extrahepatic biliary ducts previously described, into the duodenum, becoming mixed there with the other intestinal contents. In the intestinal tract nearly all of the bile pigment is absorbed, and is carried by the circulat- ing blood to the bone marrow, where the hemoglobin is resyn- thesized. The absorption is not complete, however, and enough bile pigment is lost with the ſeces to color these, which accounts for the normal light brown of the stool. In the ordinary course of events, the amount of bile pigment free in the circulating blood is small, so that the Concentration of it is too low to color the blood plasma visibly. In certain pathologic conditions, how- ever, the amount of bile pigment in the circulating blood is in- creased sufficiently to stain the plasma and to stain all the tissues of the body; it is this which constitutes jaundice. Jaundice may be produced in a number of ways. In the first place, there may be excessive destruction of red blood cells, liberating a great amount of altered hemoglobin. This is what happens in congenital hemolytic icterus and in severe reactions following the transfusion of mismatched blood. Another cause of jaundice is severe disease of the liver, in which case the liver may be so damaged that it is unable to remove the pigment com- pletely from the blood. This occurs when the liver is seriously SURGERY OF LIVER, BILIARY TRACT, PANCREAS 275 damaged by cancer, or by infectious hepatitis or the virus of homologous serum jaundice. A third Common cause of jaundice, and this is the one in which surgeons are chiefly interested, is obstruction to the extrahepatic biliary ducts, which prevents the discharge of bile from the liver and results in the regurgitation of the liver bile back into the blood vessels in the liver. Thus it is apparent that jaundice may be the sign of several quite differ- ent diseases. It is usually easy to recognize jaundice clinically, for the bright yellow tinting of the sclerae is striking. The skin is yellow, and itching (pruritus) is common and often very distressing. The urine is stained a deep brown, and can be tested to show the presence of the bile chemicals. If no bile is reaching the intestinal tract, the stool color is altered, and the feces become putty or light gray in color. It must be remembered, however, that jaun- dice may not be recognized if the patient is examined by ordinary artificial light, even though the jaundice is severe. Daylight or a blue light must be used. The relative degree of jaundice is meas- ured in the laboratory by tests on the patient's blood. One of these, the van den Bergh test, measures the amount of bilirubin in the blood plasma. DISEASES OF THE LIVER It is not remarkable that such a large and important organ as the liver is frequently the site of serious disease; unfortunately, however, only a few of these diseases are amenable to surgical treatment. Chronic degenerative disease, generalized inflamma- tory disease, and carcinoma of the liver—both primary and sec- ondary—are common, but there is no surgical treatment which is successful in these conditions. An occasional benign tumor, usually a hemangioma, occurs and is cured by operative removal. On the other hand, the injury caused the liver by obstruction or disease of the extrahepatic biliary ducts and the gallbladder can be remedied by the adequate treatment of the causative condi- tion. Liver abscess is about the only intrinsic disease of the liver which can be benefited by surgery. Pyogenic Abscess. Acute pyogenic abscess of the liver is usu- ally the result of the spread of infection from somewhere in the intestinal tract, as from an inflamed appendix, often by way of the portal vein. The portal vein, or a tributary, may be inſected (pylephlebitis). The onset of this condition is usually marked by 276 NURSING IN SURGERY OF THE ALIMENTARY TRACT chills and a high spiking type of fever. The patient is acutely ill, bacteria are often cultured from the blood stream, and jaun- dice develops. There are commonly multiple abscesses in the liver in association with pylephlebitis, and it is not practicable to drain them surgically, as they are small and too numerous to find. The treatment consists in removal of the original cause of the inſection if possible, supplemented by transfusions, anti- biotics, and other supportive therapy. The mortality rate is high. Occasionally, however, there is only a large, single liver ab- scess. This may develop quite insidiously, and may be suspected in a patient who has ſever, leukocytosis, and vague complaints of pain or discomfort reſerable to the upper abdomen. Examina- tion may reveal some enlargement of and tenderness over the liver. Diagnosis is made certain by aspiration of purulent ma- terial with a needle. The proper treatment is surgical drainage, perſormed in such a way as to prevent contamination of the peritoneal cavity. Amebic Abscess. One of the more serious Complications of amebic dysentery is the occurrence of abscess of the liver due to amebae. This is to be suspected when pain, enlargement of the liver, and fever occur in one who has amebae in his stools, or in one who has lived in a region where amebic dysentery is com- mon. It is important to differentiate this type of abscess from the ordinary pyogenic variety because surgical drainage of an amebic abscess only results in severe secondary infection and ſew cures. Such abscesses are more properly treated by aspiration and by the introduction of emetine or other antimony compounds directly into the abscess cavity. Antibiotic therapy has been found useful, tCO. CHOLECYSTITIS Inſlammatory disease of the gallbladder is called cholecystitis. There are two varieties: an acute inflammation which is similar to acute appendicitis or to any acute inflammation with all the characteristic pathologic changes, and a chronic type of inſlam mation, and with all shades of gradation between these two. It is commonly a disease of young adult and middle-aged women, but can affect either sex and people of all ages. Inflammatory disease of the gallbladder may occur with or without the ſormation of gallstones, although it is more common for the two conditions to be associated. No satisfactory explanation of the cause of disease of the gallbladder has been advanced. SURGERY OF LIVER, BILIARY TRACT, PANCREAS 277 Sympforms. The onset of acute cholecystitis is usually rather abrupt. The patient feels ill; nausea and vomiting are common. There are increasingly severe pain and tenderness in the right upper abdomen, just beneath the margin of the ribs. The patient is found to have fever, leukocytosis, and slightly elevated pulse and respiratory rates; it is often observed that respiratory move- ments are somewhat restricted, so as to avoid motion of the right upper part of the abdomen. There is definite tenderness in the right upper abdomen, and usually there is spasm of the abdom- inal muscles in that region; in some patients a tense, enlarged, tender gallbladder may be palpated. The history of a previous similar attack which subsided after a few days of illness is often given by the patient. The symptoms and signs of chronic cholecystitis are less dramatic, but may be just as distressing to the patient. There is usually the story of recurrent attacks similar to the type in acute cholecystitis, but probably less severe and shorter in duration. Such patients also complain of epigastric distress and eructation (belching) occurring after meals, especially fatty meals, and call this complaint “indigestion.” They will admit that they have learned to avoid fried foods, fats, and eggs. Often these patients suffer in addition from gallstone colic (see Cholelithiasis), for stones are frequently found in association with chronic gallblad- der disease. Complications. There are several complications of cholecystitis. During an acute attack the gallbladder may become filled with pus (empyema of the gallbladder), the wall of the gallbladder may become gangrenous, and perforation may occur. At times peri- tonitis is the sequel to this latter complication, or the perforation may take place into a sealed space, giving rise to an abscess. Another type of complication is cholangitis, the spread of in- flammation to the bile ducts both inside and outside of the liver; this may lead to serious damage to the liver. A third variety of Complication sometimes follows repeated attacks, with resultant scar formation, causing constriction which results in obstruction of the duct leading from the gallbladder (cystic duct) or of the adjacent Common duct. Treatment. The treatment of cholecystitis is surgical, and con- sists in the removal, whenever possible, of the offending gallblad- der. Surgeons are not yet in full agreement as to the proper time for the removal of the gallbladder, some surgeons feeling that it is better and safer to let an acute attack subside before they op- 278 NURSING IN SURGERY OF THE ALIMENTARY TRACT erate, others believing that the safest course is to operate at once in order to forestall the development of complications. The gen- eral condition of the patient naturally affects the decision as to the time for operation, and the type of operation performed de- pends largely on the conditions found when the abdomen is opened. CHOLELITHIASIS The presence of stones in the biliary tract is called cholelithi- asis. Gallstones are composed largely of cholesterin Crystals (cholesterin is present in large amounts in bile) and some of them have a high calcium content. Cholesterin stones are soft and are not radiopaque, whereas calcium stones are hard and throw a shadow on the roentgen film. Why these stones should form in the gallbladder and biliary ducts is not known. Stone formation is commonly associated with cholecystitis (p. 277). Gallstones often give rise to symptoms for mechanical reasons, too, even though there be no associated inflammation of the gall- bladder or ducts. It is also a fact that during the performance of routine postmortem examinations, gallstones are frequently ſound which had never given rise to any symptoms. Gallstones vary greatly in size and in number. There may be one or two very large stones, there may be two or three dozen small stones, or there may be myriads of tiny concretions resembling sand. As might seem likely, the size of the stones does have some bearing upon the course and nature of the disease. Symptoms. The most characteristic symptom of Cholelithiasis is gallstone colic, one of the severest kinds of pain to which man- kind is heir. The pain is caused by the passage, or attempted pas- sage, of a stone from the gallbladder through the cystic duct or the common duct. The pain is excruciating, it is usually felt in the right upper quadrant of the abdomen just beneath the Costal margin, and commonly there is radiation of the pain to the lower tip of the right scapula. This radiation of pain is felt characteris- tically around the surface of the right chest wall, rather than going straight through the body. Nausea and vomiting usually accompany the colic. Fever, iſ present at all, is slight, and there is no evidence of acute inflammation of the peritoneal surfaces as in acute cholecystitis. The pain may last a few minutes or sev- eral hours, and generally can be relieved only by large doses of morphine. Following the subsidence of the pain (usually due to SURGERY OF LIVER, BILIARY TRACT, PANCREAS 279 the successful passage of the stone) the patient rapidly recovers, although there may be slight persistent soreness in the right upper abdomen. Complications. Often enough a medium sized or large stone does not successfully pass through the common duct: this gives rise to obstruction which, in turn, results in jaundice. Occasion- ally a stone too large to pass through the ducts causes ulceration and pressure necrosis of the wall of the gallbladder or duct at the point where it is lodged. This may result in perforation with abscess formation, or sometimes in the formation of a false Com- munication between the biliary tract and the intestinal tract. Occasionally a stone lodges squarely in the ampulla of Vater, obstructing not only the biliary system but the pancreatic duct as well. Treatment. The treatment of gallstones is surgical. When the stones are formed in the gallbladder and at no other point the removal of that organ will cure the disease. When, however, the stones are formed in the hepatic or common ducts, those struc- tures are opened and the stones removed; the ducts must obviously be preserved, and, therefore, there is always the possi- bility of recurrence of the stone formation. Fortunately, the in- cidence of recurrence in such cases is not high. NEOPLASTIC DISEASE Carcinoma arises from any portion of the biliary tract. It is natural that the onset should be occult and insidious; jaundice is the usual first symptom. Until very recently, carcinoma arising in the liver, gallbladder, or bile ducts was regarded as hopeless, but more radical technics are now in use which may result in Cures in some cases. There is one lesion which is somewhat more amenable: this is the small cancer which arises from the ampulla of Vater. The strategic location of this tumor results in the rapid development of jaundice, leading to early diagnosis. A radical operation can be performed with expectation of permanent cure in favorable cases. DHAGNOSIS OF BILIARY TRACT DISEASE In the majority of instances, disease of the biliary tract can be diagnosed by the characteristic symptoms and signs of the dis- ease, but in some patients the symptoms and signs are vague and atypical. There are, in addition, a great many other conditions 280 NURSING IN SURGERY OF THE ALIMENTARY TRACT Figure 80. Cholelithiasis. The nonopaque cholesterin stones appear as holes in the gallbladder as outlined by tetraiodophenolphthalein on the x-ray film. of the upper abdomen which may be easily confused with biliary tract disease, including peptic ulcer, pancreatitis, liver abscess, kidney disease, and a number of less common conditions. The diagnostician has available, however, an excellent method of examining the function of the biliary tract, the gallbladder dye test devised by Graham and Cole. This test is based upon the fact that tetraiodophenolphthalein, a radiopaque chemical, is excreted from the blood into the bile by the liver. In the same way that the gallbladder concentrates bile it concentrates the radiopaque dye in the normal gallbladder sufficiently to throw a shadow outlining the gallbladder upon the x-ray film. The value of this test depends largely upon the care with which the patient is prepared and the method by which the dye is administered. When the dye is given by mouth it is obvious that the amount which can be secreted in the bile depends upon the efficiency of the absorption of the dye from the intestinal tract. SURGERY OF LIVER, BILIARY TRACT, PANCREAS 28 I If the gallbladder is outlined by this test, it is safe to assume that the function of the biliary tract is not far from normal. In such a gallbladder, however, the presence of nonopaque choles- terin stones may be demonstrated. These stones will appear as holes in the gallbladder shadow. Calcium stones are visible in the plain x-ray film. If the gallbladder cannot be visualized it is safe to assume that there is altered function of the gallbladder, a definite evidence of a diseased biliary tract. If, in such cases, the same result follows the administration of a double dose of the dye, the evidence for biliary tract disease is a little more con- clusive. A synthetic drug called Priodax (8|4-hydroxy-3,5-diiodophenyl]- a-phenyl-propionic acid) has been introduced. It is much pleas- anter to take and causes less gastrointestinal irritability than tetraiodophenolphthalein. Nursing Care. Preparation of the patient for cholecystography begins by giving the patient a fat-free supper, followed by six tablets, 0.5 gm. each, of iodoalphionic acid (Priodax). Explana- tion should be made to the patient that no eggs, cream, butter or other fats should be eaten. Black coffee, clear tea and water are permitted. No purgatives, food or drink other than the liquids mentioned may be offered after supper. The nurse should find out what the patient knows about this painless procedure, and should explain that it will include two x-rays in the morning and one after a fatty meal at noon. Apprehension which precedes the unknown is minimized by a simple and straightforward explana- tlCIl. To enhance visualization, an enema is given in the morning about a half hour or an hour before the first x-ray. In some clinics, two enemas are ordered, given one-half hour apart. The second enema is given to further insure the evacuation of gas which, when present, prevents good visualization. The nurse should be aware that complaints of slight nausea may occur after taking the dye in about 25 per cent of the pa- tients. The drug is ultimately excreted in the urine; it causes pain on urination in about 5 per cent of the cases. OPERATIONS ON THE GALLBLADDER AND BILIARY DUCTS Cholecystectomy. The most frequently performed operation is the removal of the gallbladder, termed cholecystectomy. The gallbladder is easily exposed through an incision in the upper right abdominal wall. Care is taken to identify the common duct, 282 NURSING IN SURGERY OF THE ALIMENTARY TRACT | \ Midline Lièation of cystic, e.* duct | & º º §ºf º &Z É £3. Common bilz duct Duodenum FIGURE 81. Cholecystectomy. the cystic duct, and the cystic blood vessels which are branches of the hepatic artery and portal vein. The cystic duct and vessels are divided and ligated, aſter which it is easy to remove the gall- bladder. Most surgeons place a cigarette drain in the wound, the inner end of the drain being near the stump of the cystic duct. This is done so that iſ leakage occurs the bile will escape from the wound rather than spread over the entire peritoneal cavity. This drain is generally left in place ſor five or six days, at the end of which time it may be safely assumed that the danger of leakage is over. * Cholecystofomy. The simple opening of the gallbladder, chole- cystotomy, for the purpose of drainage of the bile or the removal of stones, is less frequently performed than it was a few decades ago. This procedure is at best only palliative, and must be fol- lowed later, in order to cure the patient, by cholecystectomy. Cholecystotomy is valuable, however, as an emergency procedure in a debilitated patient who would be a poor operative risk for a more extensive operation. SURGERY OF LIVER, BILIARY TRACT, PANCREAS 283 FIGURE 82. T tube. Other Operations. Occasionally it is necessary to open and ex- plore the common duct. This procedure is called choledochot- omy; if this is done for the removal of stone it is called chole- docholithotomy. Stricture of the common duct, a most serious Condition, is sometimes present as a congenital anomaly and sometimes is the result of disease or improper surgery. Plastic operations are undertaken upon the common duct for the relief of these conditions. In certain cases when there is an obstruction in the terminal portion of the common duct, as in cancer of the head of the pan- creas, or when some operative procedure has necessitated removal of this terminal portion of the duct, it becomes necessary to make a new connection (anastomosis) between the biliary and alimentary tracts. One method is to anastomose the gallbladder to the stomach (cholecystgastrostomy); a more satisfactory method when possible is to reimplant the common duct into the duodenum (choledochoduodenostomy), or jejunum (choledocho- jejunostomy). Many surgeons use a T tube in operations on the Common duct. By this means, the passage of bile from the liver to the intestine can be made certain. Furthermore, radiopaque solutions may be introduced into the ducts, so that residual stones or obstructions can be visualized (cholangiography). Nursing Care. In general, the nursing care of patients who have had operations upon the gallbladder or bile ducts is the same as ſor other patients who have undergone a laparotomy (p. 233). It should be remembered, in addition, that operative pro- cedures carried out in the upper part of the abdomen are par- ticularly likely to be followed by restriction of respiratory move- ments incident to the pain and muscle spasm in the operative area. Distention, too, is almost always more severe following 284 NURSING IN SURGERY OF THE ALIMENTARY TRACT biliary tract surgery than it is in other uncomplicated laparoto- mies. Extra effort must be made, therefore, to encourage the patient to breathe fully and to cough. Frequent turning of these patients is also an aid in keeping the lungs expanded; turning helps to stimulate peristalsis as well, and thus aids in the control of distention. Synthetic vitamin K is routinely administered to jaundiced pa- tients before and after operation; 4.8 mg. injected intramuscu- larly each day is adequate therapy. It is important to supply vitamin K because this substance is essential to the production of prothrombin, a vital element of the coagulating mechanism of blood. Vitamin K is ordinarily absorbed in the alimentary tract from the diet, but is not absorbed when bile does not reach the tract. There are no special precautions to be taken with respect to the postoperative feeding of these patients but, as a rule, fluids and food are not readily taken during the first two or three days. The jaundiced patient is a difficult problem for the nurse and dietitian because he has no appetite or even has a positive distaste for ſood. The same is usually true of patients having a biliary fistula. The loss of all or a large part of the bile from the digestive tract causes considerable disturbance in digestion as well as loss of appetite; improvement may follow the administra- tion, usually by stomach tube, of the lost bile. DISEASES OF THE PANCREAS Pancreatitis. Acute pancreatitis, a fulminating and serious in- flammation of the pancreas, is characterized by the abrupt onset of severe upper abdominal pain, vomiting, rapid pulse, and pros- tration. The cause of this disease is not known. Patients having acute pancreatitis are almost invariably subjected to laparotomy because the clinical picture of the disease so closely resembles those of acute cholecystitis and perforation of a peptic ulcer that they cannot be safely treated without exploration. The amylase test is helpful in differentiating pancreatitis from other diseases. This test depends upon the appearance in the circulating blood of abnormal amounts of amylase, the starch-splitting enzyme secreted by the pancreas. At operation the pancreas is seen to be swollen and hemorrhagic, and there are areas of necrosis in the neighboring ſat as the result of the escape of the potent pan- creatic enzymes. Many of these patients recover and it is likely that they would do as well iſ not operated upon. SURGERY OF LIVER, BILIARY TRACT, PANCREAS 285 Recovery from this disease may rarely be followed by diabetes mellitus or by the formation of a pancreatic cyst. Such cysts some- times grow to large size and then require surgical treatment. Some cysts can be removed but others must be treated by making a connection between the interior of the cyst and the stomach or jejunum (internal drainage), or between the cyst and the ex- ternal abdominal wall (marsupialization). Chronic pancreatitis causes attacks of severe pain. No form of treatment has been ſound to affect this condition directly, but the pain can be relieved by division of the sympathetic nerves to the upper abdomen. Resection of Pancreas for Carcinoma. Carcinoma of the pan- creas is not uncommon. As in other forms of abdominal cancer, the onset is insidious: in most instances the tumor has spread beyond the point where it can be cured before symptoms occur. Such a tumor arising in the head of the pancreas Commonly makes itself known by obstructing the common biliary duct, re- Sulting in a progressive and usually painless jaundice. Surgical treatment is being used more frequently for this condition, and essentially the same operation is performed as for cancer arising in the ampulla of Vater. The surgeon removes the entire duo- denum, the pancreatic end of the common bile duct, part or all of the pancreas, and sometimes the spleen. The stomach and cen- tral end of the common bile duct are anastomosed to the jejunum. Despite this extensive procedure, the patient may have little disability afterward unless total removal of the pancreas was carried out; in that event, the patient becomes a total diabetic and needs insulin and careful attention to the diet. Nursing Care. The preparation for operation depends largely upon the condition of the patient. When the patient is jaundiced and dehydrated, parenteral fluids and vitamin K are adminis- tered. There has usually been a loss of weight and the appetite is below normal. The nurse should try to encourage the patient to eat food which is high in calories, protein and vitamins. The nurse should give this patient and his family emotional support: first, by winning their confidence with a careful ex- planation of the happenings on the ward, and second, by answer- ing questions, to reinforce their confidence in the surgeon and staff. Making the patient feel as secure as possible by kind and patient attention is the way to minimize anxiety. The patient with a total or partial resection of the pancreas is usually rather unhappy during his convalescence. The many 286 NURSING IN SURGERY OF THE ALIMENTARY TRACT urine and blood tests required to determine his diabetic status and the regulation of diet are new to him and do not add to his comfort. His appetite is poor and he feels weak. He sometimes shows resentment, often focusing upon the diet. Patience and much kindness is necessary to encourage him to eat; repeated assurance that he is doing well is advisable. During his stay in the hospital the essentials of food and nu- trition should be taught. When he is a diabetic and he is to receive insulin when he goes home, the same careful instructions given to all diabetic patients must also be given to him." The need for follow-up care should be carefully understood by pa- tient and family before discharge. SUMMARY Surgeons deal successfully with inflammation and stones in the ducts of the liver, in the gallbladder, and in the common duct. Neoplastic disease presents greater difficulties. The causes of stone and inflammation are not known although removal of the gallbladder for these conditions is one of the most commonly performed and completely curative procedures in surgery. The causes of pancreatic inflammation are likewise obscure, and their treatment about as unsatisfactory as the treatment of cancer in that Organ. VOCABULARY REVIEW ampulla of Water cholecystectomy cholecyst- jaundice T tube jejunostomy cholecystitis cholesterin pancreatitis chole lithiasis cholangiography SUGGESTED READING 1. Buckley, Marie, and Crenshaw, Virginia P.: Nursing Care of a Patient with Cholecystitis. Am. J. Nursing, 46:812-815 (December) 1946. 2. Christopher, Frederick: A Textbook of Surgery. 5th Ed. Philadelphia, W. B. Saunders Co., 1949. 3. Diffenbaugh, Willis G., and McArthur, Selim W.: Mortality and Morbidity in Surgery of the Biliary Tract. Arch. Surg., 59:1070–1076 (November) 1949. 4. Kirklin, B. R., and O’Donnell, D. B.: Present-Day Cholecystography. J.A.M.A., 151:261-265 (January 24) 1953. . McGowan, John M.: Dynamics of Biliary Drainage. Surgery, 18:470-478 (October) 1945. 5 1 See Brown, pages 650-695. SURGERY OF THE SMAILL INTESTINE AND APPENDIX 287 6. Proudfit, Fairfax T., and Robinson, Corrinne Hogden: Nutrition and Diet Therapy. 10th Ed. New York, The Macmillan Co., 1951. 7. Whipple, A. O., Parsons, W. B., and Mullins, C. R.: Treatment of Carcinoma of Ampulla of Vater. Ann. Surg., 102:763–779 (October) 1935. CHAPTER 26 Surgery of the Small Infestine and Appendix The final digestion and absorption of the nutritive material con- tained in food are accomplished in the small intestine. The fluid, pulpy material which is finally emptied into the large intestine (colon) contains little but water, mucus, indigestible fibers of vegetable origin, and cellular debris. On the average, this end- result of digestion reaches the colon three to five hours after meal- time. The chief function of the colon is the reabsorption of the considerable amount of water, another example of the remark- able efficiency of the human body in the conservation of needed materials. By the time the intestinal content reaches the lower end of the colon, the rectum, it has been converted into the familiar semisolid feces. One or more times daily this material is finally evacuated from the body during the act of defecation. THE ILEUM AND JEJUNUM The uppermost portion of the small intestine, the duodenum, is but 12 inches in length. The remainder of the small intestine is about 20 feet in length, of which the upper portion is jejunum and the lower part is ileum. There is not much difference in the appearance of the jejunum and the ileum, although the latter is somewhat thinner walled and smaller in caliber. The chief dif- ference is in the type and function of the digestive glands which line these two portions of the small intestine. One of the most remarkable things about the small intestine is the paucity of diseases which affect it despite its great length and the constant wear and tear to which it is subjected. 288 NURSING IN SURGERY OF THE ALIMENTARY TRACT Inflammatory Lesions Perforation of the Ileum. At the present time, because of the splendid efforts of physicians and public health officials, typhoid is a rare disease; perforation of the ileum is, however, a common Complication. Diagnosis is difficult because the patient is already so ill that the onset of peritonitis may be obscured. For this rea- son it is common practice for the surgeon to palpate the abdo- men of each typhoid patient every day, so that the slightest change is more likely to be noted. The treatment consists in sim- ple closure of the perforation, which obviously must be carried out within the first few hours in order to save the patient's life. Regional Enferitis. There is a little understood, chronic, granu- lomatous lesion of the small intestine which is called regional enteritis. This may affect any portion of the small intestine, but is most likely to occur in the terminal ileum, in which case it is called terminal ileitis. The cause is not known. In the early stages of the disease the clinical picture includes Crampy abdominal pain, fever, and diarrhea. Very often a mistaken diagnosis of ap- pendicitis is made and appendectomy is performed. Later in the disease the symptoms may be less acute and the cramps and diar- rhea occur intermittently. Blood can always be detected in the stool. Careful fluoroscopic observation of barium passing through the small intestine may show abnormal intestinal patterns or actual deformity of the bowel which confirms the diagnosis. Because of the frequency of widespread involvement of the in- testine, patients with this disease should be operated upon only if such Complications as ileus or the formation of fistulas occur. Antibiotic therapy is helpful but not curative. Tuberculosis. The small intestine is not infrequently the site of tuberculosis. This is nearly always but one manifestation of a generalized tuberculous infection. Unless obstruction occurs, the treatment is the same as that given other forms of tuberculosis, namely, rest, antibiotic therapy, and other measures undertaken to increase the patient's resistance to the infection. Subcutaneous Injuries to the Abdomen Nearly everyone is familiar with the damage inflicted upon the abdominal Organs by penetrating wounds of the abdomen. The need for prompt surgical exploration in order to arrest hemorrhage and close perforations of the alimentary tract is well understood. It is not so commonly known that a hard blow upon the abdo- SURGERY OF THE SMALL INTESTINE AND APPENDIX 289 men, which need not damage the abdominal wall in any way, may produce rupture of the liver or spleen, or may tear the in- testinal wall. Such injuries are caused by the sudden displacement within the abdomen of the abdominal contents; where these viscera and contents are relatively fixed in position and cannot quickly adjust themselves to meet the applied force, damage is likely to occur. An example of this is the upper end of the jejunum which is firmly fixed to the posterior abdominal wall by the ligament of Treitz. Any patient who has received a kick or other hard blow in the abdomen, or who has received a crushing injury to the abdomen, should be carefully observed for several hours. If there is per- sistent pain, or if the signs of internal bleeding or of peritoneal irritation appear, the abdomen should be explored so that the internal injury can be repaired. Neoplcisms of the Small Intestine Tumors of the small bowel are rare. This fact is difficult to explain, particularly since tumors of the alimentary tract just above and just below the small intestine are fairly common. Benign papillomas and hemangiomas of the mucous membrane of the small intestine are occasionally found, and make their presence known by the occurrence of hemorrhage. Fluoroscopic studies may reveal the presence of these small tumors. Cure is effected by surgical removal. Malignant tumors are extremely rare, and can seldom be diagnosed sufficiently early to be cured. OPERATIONS ON THE SMALL INTESTINE Jejunosfomy. Under Some circumstances it is desirable to have an opening into the upper portion of the small intestine through which the patient may be fed. This opening (jejunostomy) is usually made into the uppermost segment of the jejunum and is carried out in exactly the same manner as is a gastrostomy. Ileosfomy. For very different reasons, an entirely similar procedure (ileostomy) is carried out on the lowermost segment of the ileum: here the purpose is to afford an outlet to the ali- mentary tract when, for some reason, it seems desirable not to utilize the colon. This operation is commonly performed in the treatment of chronic ulcerative colitis, and the details of ile- ostomy care are given in the section on that disease (page 302). Resection. It is occasionally necessary to remove segments of the bowel (intestinal resection). The continuity of the alimentary 290 NURSING IN SURGERY OF THE ALIMENTARY TRACT º: º *z, *, * * * * * - —s º 42 • t § ſº gº § Ža º ‘..., * t?72.2 Ş WS ( (ſſſſia, ſº d g !? § *} t" * º Wººl, . ºf § W N º § §. Å t * * FIGURE 83. Intestinal anastomosis. A, End-to-end; B, side-to-side (lateral). tract can be reestablished in several ways, by joining together the remaining ends of the intestine (end-to-end anastomosis), by clos- ing one end and joining the other end to the side of the first (end- to-side anastomosis), or by closing both of the remaining ends and creating a new opening between the sides of the two seg- ments of bowel (side-to-side or lateral anastomosis), as illus- trated in Figure 83. MECHANICAL ILEUS One type of intestinal obstruction, paralytic ileus, has already been discussed in connection with peritonitis (Chap. 23). In- testinal obstruction is also commonly produced by mechanical causes. Some of the more frequently encountered causes of me- chanical ileus are strangulated hernia, bands of adhesions after peritonitis, rotation or twisting of the bowel (volvulus), telescop- ing of the bowel within itselſ (intussusception), and tumors which occlude the lumen of the intestine either by growth inside of the intestine or by pressure from without. Mechanical ileus is a serious condition and results in the death of the patient unless the obstruction is promptly and effectively relieved. Because of the variety of conditions that can cause this disease, persons of all ages and both sexes are affected. Symptoms. The four cardinal symptoms of mechanical ileus are Cramplike abdominal pain, vomiting, distention, and Con- stipation. Of these, in acute obstructions, the cramps are the earliest and most important symptom. The onset of vomiting may be within a few minutes, or may be delayed. The progression and severity of the symptoms depend upon the degree of obstruction and the anatomic position at which it occurs. When the block is in the upper portion of the small intestine the symptoms de- velop quickly and are violent; when the terminal portion of the small bowel or the colon is obstructed the onset of symptoms may SURGERY OF THE SMALL INTESTINE AND APPENDIX 291 - Figure 84. X-ray film of abdomen taken in upright position. Distended loops of small intestine containing gas and fluid are visible, but no gas is seen in large intestine. This patient had mechanical ileus. be more insidious. In the latter case, particularly if the colon is involved, constipation and slowly developing distention of the abdomen are likely to be the first symptoms. It is obvious that the patient who has intestinal obstruction quickly develops dehydration and disturbance of his chemical balance. There is also grave danger that, just as in paralytic ileus, overdistention of the bowel will result in necrosis and per- foration of the intestinal wall, leading to peritonitis. It is also thought by some that the absorption of toxic substances from the intestinal contents takes place, and that this absorption, which does not occur when the bowel wall is normal, is responsi- ble for the severe prostration which is part of the clinical picture. 292 NURSING IN SURGERY OF THE ALIMENTARY TRACT Diagnosis. One of the most difficult problems in surgery is the differential diagnosis between mechanical and paralytic ileus. It is essential for the surgeon to know with which of these condi- tions he is dealing, because the treatment of the one is nearly the opposite to that of the other. Considerable light is thrown upon this subject by the history of the illness; in the absence of those Conditions which are known to cause paralytic ileus (e.g., perito- mitis or recent laparotomy), symptoms of ileus point to a mechanical cause. If, however, the peritonitis or laparotomy oc- curred several weeks or longer before symptoms of ileus pre- sented, the possibility of an obstructing band of adhesions must be considered. When the ileus is caused by the strangulation of a hernia, the correct diagnosis is readily made by examination of the patient and recognition of the hernia. In general, severe and persistent Cramping pain is characteristic of mechanical ileus, ſor the pain is due to the violent peristaltic action of the intestine above the obstruction as it attempts to overcome the block. Usually this pain does not occur in paralytic ileus, for in this Condition the bowel wall is atonic. An x-ray film of the abdomen taken in the upright position is often of great diagnostic aid. The loops of intestine above the point of obstruction, being filled with gas and fluid, are readily visible and of characteristic appear- ance. Finally, the abrupt onset of the symptoms of ileus in a pa- tient not previously ill is strong evidence for the presumptive diagnosis of mechanical obstruction. Trecitment of Mechanical lleus The Conservative nature of the treatment of paralytic ileus has already been mentioned (Chap. 23). This treatment might be successful in certain instances of mechanical obstruction, par- ticularly in those cases in which the circulation of the obstructed bowel is not impaired. Unfortunately, however, there is no safe way of determining the status of that circulation other than by exploratory operation. All of the therapeutic measures used in the treatment of paralytic ileus are employed in mechanical ob- struction and for the same reasons, but the most important meas- ure is the relief of the mechanical block. This usually necessitates laparotomy. The need for intravenous fluids is obvious. Anti- biotic agents, especially penicillin, have proved to be beneficial and should be administered at once. Decompression. Distention is combated by the use of an in- SURGERY OF THE SMALL INTESTINE AND APPENDIX 293 lying nasal tube to which is attached a constant suction appara- tus (Fig. 71, p. 244). The Miller-Abbott tube, a long double- lumen tube to the lower end of which is attached an inflatable rubber balloon, is especially useful in such cases. By having the patient lie on his right side the end of the tube is more easily passed through the pylorus. When this has been accomplished, as adjudged by the changing character of the fluid obtained from the tube or by its position as seen under the fluoroscope, the balloon is partially inflated. The peristaltic contractions of the small intestine seize this balloon and propel it down the alimen- tary tract, dragging the tube along with it. The loops of intestine are thus successively decompressed, and the tube may reach the point of obstruction. This procedure, by virtue of the decompres- sion accomplished, may actually relieve the obstruction; unless this takes place in a very few hours after the onset, however, the treatment is not safe because of the danger of circulatory impair- ment already mentioned. Some surgeons prefer the Cantor tube, a single lumen tube to the end of which is attached a balloon Con- taining a small amount of liquid mercury. Choice of Operation. Operation should be undertaken as soon as the diagnosis has been established and the condition of the patient rendered more favorable. As a general rule, the best re- sults follow operative procedures which deal directly with the cause of the obstruction; palliative procedures such as enter- ostomy above the obstruction or short-circuiting anastomoses around the obstruction are occasionally life-saving but are usu- ally unsatisfactory. In cases where the circulation of the Ob- structed loop has been impaired, as in strangulated hernia, Con- stricting bands of adhesions, or volvulus, the appearance of the bowel is carefully observed for ten or fifteen minutes after the constriction has been relieved; in many instances the loop of bowel is obviously so badly damaged because of the lack of cir- culation that it must be removed. These patients are seriously ill, however, and stand operation poorly; only such procedure as is absolutely necessary should be carried out. Nursing Care. The patient is usually admitted as an emergency. Dehydration, poor color and great pain, frequently accompanied by listlessness, are the signs and symptoms that are seen. The patient may be apprehensive about his illness and what has to be done if he is alert, but also gives evidence of great relief in being admitted because he knows that something will be done 294 NURSING IN SURGERY OF THE ALIMENTARY TRACT to relieve his excruciating pain. The nurse will have to judge ac- Cording to his condition how much explanation can be given to- ward emotional support. Suffice it to say that it is good to explain simply and specifically what procedure is going to be done; more than this is often not understood. The principles of care are those used ſor the patient with paralytic ileus (p. 242), namely withdrawal of the fluid and air from the intestines, antibiotics and parenteral fluids. As soon as the drainage of fluid and air is established, the pain produced by the ſorceſul peristalsis begins to decrease. Accurate measurement of intake and output are essential. Iſ an immediate operation is to be done, drainage of the stomach is usually done by means of a Levine tube and the tube is left in place. The immediate pre- operative preparation consists only of shaving the abdomen and administering the preoperative medication. Following operation, suction drainage is continued. Parenteral ſluids and antibiotics are given. Electrolyte balance is often diſ. ficult to achieve and is estimated from determinations of the blood chemistry and the urinary output. The drainage from the tube will decrease as the patient improves; the output of urine will be 1000 cc. or more. The general care of any patient with abdominal surgery is applied. Each patient is treated individually according to his need. When recovery seems assured, it is time for the nurse to begin health teaching regarding nutrition, cleanli- ness, and follow-up care. THE APPENDIX The vermiform appendix, so called because of its resemblance to a worm, is attached to the first portion (cecum) of the large intestine, close to the junction of the cecum and terminal ileum (ileocecal junction). This vestigial organ serves no known func- tion in the human being. The structure of the appendix is like that of the intestinal tube in general, and its mucous membrane resembles that of the cecum with which it is continuous. At the base of the appendix its lumen communicates with that of the cecum; at the other end the lumen ends blindly, a fact which is undoubtedly responsible, in part, ſor the ſrequent inſlammation of this organ. Although it is usually about the size and shape of a little finger, the appendix in different patients may vary greatly in length (3 to 20 cm.) and in position. It may lie ſreely in the peritoneal cavity, it may hang down into the pelvis, it may lie SURGERY OF THE SMALL INTESTINE AND APPENDIX 295 along the lateral border of the cecum, or it may be located behind the cecum (retrocecal). Acute Appendicitis Acute appendicitis is a common disease, affecting people of all ages. It is a most treacherous disease, and the proper treatment is the prompt removal of the appendix (appendectomy). The im- portance of making an early diagnosis, therefore, cannot be over- emphasized. Every patient who complains of spontaneous and persistent lower abdominal pain and who has recognizable ten- derness in the region of the appendix must be suspected of hav- ing appendicitis and must be treated for it unless some other cause of his symptoms can be satisfactorily demonstrated. The re- cent decrease in the death rate from this disease is largely at- tributable to the extensive efforts which have been made to inform the public about these facts. There is no place for home remedies in the treatment of appendicitis. Symptoms. The first symptom is usually Cramplike abdominal pain, ordinarily in the region of the umbilicus. Within a few hours this pain increases in severity, becomes more constant, and gradually shifts to the right lower quadrant of the abdomen. Nausea and vomiting Commonly occur, and the patient at this time has fever and protective spasm of the muscles of the right lower abdomen. Diagnosis. Palpation of the lower right abdomen causes pain: the point of greatest tenderness is usually found midway between the umbilicus and the anterior superior spine of the right ilium (McBurney's point). In addition, there is an increase in the num- ber of white blood cells (leukocytosis). In many persons, however, the symptoms and signs of this disease are less typical and there is often difficulty in making a Correct diagnosis. There are, in addition, many other diseases which give rise to symptoms and signs so similar to those of ap- pendicitis that mistakes in diagnosis are difficult to avoid. Among the diseases which must be considered in the differential diag- nosis are acute pyelitis, renal or ureteral colic, food poisoning, gallbladder disease, and, in females, lesions of the ovary and tube. Complications. The Complications of improperly treated or un- treated acute appendicitis are dangerous. The inflammation of the appendix is often fulminating and within a few hours to two or three days, the wall of the appendix may become gangrenous; 296 NURSING IN SURGERY OF THE ALIMENTARY TRACT §§ SSRY: Nº W Niš Y sº ºw | y ºš \ \!? |\º * º Nº. :=# Ś sy,\\. Ż-sº A-4K wº §§ sº sº d | ſ £º º º Czcum FIGURE 85. Appendectomy. Following division and ligation of the appendix and its mesentery the appendical stump will be inverted into the cecum beneath the purse-string suture which has already been placed in the cecal wall. perforation often occurs. Depending upon the position of the appendix within the abdomen, and upon the speed of the inflam- matory process, either generalized peritonitis or a local abscess may result from perforation. The gravity and complications of peritonitis are discussed in Chapter 23. Mechanical ileus some times occurs later as the result of inflammatory adhesions caused by appendicitis. Not infrequently during the course of appendi- citis bacteria enter the veins of the appendix. Since these are tributaries of the portal venous system, pylephlebitis may occur with subsequent formation of multiple abscesses in the liver. All of these complications are prevented by the removal of the ap- pendix early in the attack. It is significant that the mortality rate from acute appendicitis treated by appendectomy before perfora- tion of the appendix had occurred was less than 0.1 of 1 per cent in several large series of patients treated in large metropolitan hospitals. On the other hand, in these same clinics the mortality from acute appendicitis in which perforation did occur was about 10 per cent, prior to the introduction of antibiotic agents. The mortality rate has fallen much below this figure as a result of the use of antibiotics; nevertheless, the best therapy of these dangerous complications lies in their prevention. SURGERY OF THE SMALL INTESTINE AND APPENDIX 297 Unfortunately, there are still too many patients who do not seek medical aid until after perforation of the inflamed appendix has occurred. The treatment of these patients depends upon their condition and upon the nature of such complications as have de- veloped. Dehydration, chemical imbalance, and paralytic ileus must be promptly and strenuously treated when they occur. Sur- geons do not yet agree as to the proper time for appendectomy under such Conditions and each case must be judged according to circumstances. Spreading infection is combated by the use of antibiotic agents and by the removal of the cause of the infection as soon as the patient's Condition warrants the operative pro- Cedure. If a localized abscess has formed, this is drained, and appendectomy may be postponed until a later date. The forma- tion of intraperitoneal abscess is a common complication of per- forative appendicitis; such abscesses usually form in the pelvis, but occasionally are found beneath the diaphragm (subphrenic abscesses). Abscess formation is to be suspected by the onset of ſever, pain, and leukocytosis in a patient apparently making a satisfactory convalescence. Pelvic abscess can be diagnosed by palpation of the abdomen and by rectal examination; subphrenic abscess is more difficult to diagnose and can be detected only when the physical signs appear or x-ray evidence is demonstrated by displacement of the liver or elevation of the diaphragm. In suspected cases the diagnosis may be confirmed by introduction of a needle and aspiration of pus. Nursing Care. Since the patient with acute appendicitis is usu- ally admitted as an emergency, the first contact the nurse may have is when the patient returns from the operating room. She may learn from his chart if he has ever been in a hospital, what his previous illnesses have been and information concerning his family. These facts will aid her in ſormulating ideas about an appropriate approach to him and his family. Good nursing care postoperatively is first directed toward the prevention of complications which may result from the use of anesthesia. Vital signs must be carefully observed. The patient is encouraged to breathe deeply, to Cough, and to turn each hour after he awakens. The patient is permitted up according to the individual surgeon's plan, usually the day following operation. He may have diet as tolerated. This operation is now considered One of the less traumatic ones but the nurse should bear in mind that any hospital experience may have a severe psychologic im- pact upon the patient. In uncomplicated cases, the patient leaves 298 NURSING IN SURGERY OF THE ALIMENTARY TRACT the hospital in three or four days and may return to full activity in a week. The patient with appendicitis and his family often afford a fine teaching opportunity to the nurse. It has been stated that about 90 per cent of the patients who have appendical perfora- tion have taken a cathartic at the onset of the disease. Because of this cathartics are contraindicated whenever a patient has a pain in the abdomen, especially if the patient is a child. The best nursing care for the patient, until the doctor is available, is to put the patient to bed, keep him quiet and permit him to have only a liquid diet. The nursing care when the patient has appendicitis with per- foration varies according to the treatment which, in turn, de- pends on the severity of condition. An intestinal tube is inserted when needed to deal with paralytic ileus. Repeated enemas are given if distention develops. Antibiotics are given to combat the existing infection. The nurse observes the vital signs carefully for there is usually an increase in the pulse rate, followed in a few hours by a tem- perature rise, when there is abscess formation. When such an in- cident occurs, it should be reported. The position of the patient in bed should be in accordance with the doctor's Order; some- times, the patient is kept flat while, at other times, the head of the bed is elevated in an effort to encourage the infection to gravitate into the pelvis. Additional points of nursing care include those described in Chapter 23, page 240. MECKEL’S DIVERTICULUM Meckel's diverticulum is a blind pouch arising from the wall of the ileum, usually I to 2 ſeet above the ileocecal valve. This pouch is the remnant of the duct which connects the intestine and the yolk sac during the first few weeks of ſetal life; in most people this duct is completely obliterated prior to birth, but in 1 or 2 per cent a part of it persists and forms this diverticulum. Although many persons have this congenital anomaly all their lives, symptoms are produced only if the diverticulum becomes the seat of a pathologic process. Acute inflammation (diverticulitis) does occur and its symptoms and signs are indistinguishable from those of acute appendicitis. Since this is so, where surgeons find an uninſlamed appendix when operating upon a patient sus- pected of appendicitis, they should always inspect the lower SURGERY OF THE SMALL INTESTINE AND APPENDIX 200 ileum in order that an acutely inflamed Meckel's diverticulum be not overlooked. The proper treatment for lesions of Meckel's diverticulum is removal (diverticulectomy). Occasionally an interesting lesion of Meckel's diverticulum is responsible for intestinal hemorrhage. This occurs when a typical peptic ulcer develops in the gastric type of mucous membrane which frequently lines the diverticulum. SUMMARY Despite the great length and importance of the small in- testine, it is seldom the primary site of disease, and is only oper- ated upon when damaged by injury or involved in disease of adjacent viscera. Mechanical ileus is a common affliction and re- quires accurate recognition and prompt, strenuous treatment. Acute appendicitis is of very frequent occurrence; when recog- nized early and treated by appendectomy, the results are uni- formly good; the complications of neglected appendicitis can be lethal. VOCABULARY REVIEW ileum jejunostomy resection ileus appendectomy regional jejunum McBurney e?! term il S SUGGESTED READING 1. Christopher, Frederick: A Textbook of Surgery, 5th Ed. Philadelphia, W. B. Saunders Co., 1949, pp. 1027–1038. 2. Ladd, William E., and Gross, Robert E.: Abdominal Surgery in Infancy and Childhood. Philadelphia, W. B. Saunders Co., 1941, pp. 155–164. 3. Mullins, Elise: Ruptured Appendix with Peritonitis. Am. J. Nursing, 49: 672, 1949. 4. Stafford, Edward S., and Scott, H. William: The Mortality of Appendical Perforation. South. Med. J., 41.834 (September) 1948. 5. Wangensteen, Owen H.: Intestinal Obstruction. Springfield, Ill., Charles C Thomas, 1942, pp. 3–261. 6. Waples, Genevieve, and Thompson, Bernice: Colostomy Care: I. The Use of the Lamson Appliance; II. The Use of the Buikley Colostomy Irigator. Am. J. Nursing, 48:233–235 (April) 1948. 7. Wolſt, William I., and Hindman, Robert: Acute Appendicitis in the Aged. Surg, Gynec. & Obst., 94:239–247 (February) 1952. CHAPTER 27 Nursing in Colon Surgery The large intestine is composed of the thin-walled cecum and ascending colon, which occupy the right lateral portion of the abdominal cavity, the transverse colon which crosses the upper abdomen and from which depends the apronlike omentum, the thick-walled descending colon which lies along the left lateral margin of the abdomen and, finally, the sigmoid colon, so named for its S-shaped curve, which becomes the rectum as it passes through the lower border of the abdominal cavity. It is interest- ing that these portions of the colon differ not in their anatomic locations alone: the structure, the nature of their blood Supply, and the nature of the pathologic processes which affect them are different. |NFLAMMATORY LESIONS OF THE COLON Food Poisoning. Probably the commonest ſorm of Colitis is that encountered in acute food poisoning. It is hardly necessary to point out that the treatment of this condition is not surgical, but unfortunately the symptoms may easily be and often are mistaken for those of acute appendicitis. Chronic Ulcerative Colitis. A much more formidable disease, al- though far less common, is chronic ulcerative colitis.” The cause of this condition is not known. Young adults of both sexes may be affected. As the name implies, the mucous membrane of the colon becomes ulcerated; characteristically involving only the sigmoid and rectal portions of the large intestine in the early stages, the disease may progress to involve the entire Colon. Symptoms. At first the symptoms are mild, and the patient notices only a slight increase in the frequency of evacuation of his bowel; later the patient complains of severe lower abdominal Cramps, frequent diarrheal stools containing blood and pus, loss of weight, and weakness. This disease is characterized by spon- taneous remissions so that a patient, apparently very ill, may suddenly improve and recover completely. In many cases, how- ever, the course of the disease is less favorable. Treatment. As in other inflammations, the most beneficial 1 See Brown, pages 528–532. 300 NURSING IN COLON SURGERY 301 therapeutic principle is that of rest. To accomplish this, all food and fluid by mouth are withheld, and the patient is maintained in metabolic balance by total intravenous alimentation, includ- ing vitamins. Antibiotic agents are administered to combat the bacteria always present in the colon. ILEOSTOMY. In patients who do not respond sufficiently to such treatment, the colon may be put to rest surgically; this is accom- plished by the performance of an ileostomy, done in such a way that all of the intestinal content is expelled from the ileostomy and none is permitted to enter the colon. Following this opera- tion many of the patients do very well and are able to resume their usual activity. The colon appears to heal, but careful exam- ination often reveals persistence of the inflammation despite the fact that the colon is functionless. It is only in an occasional patient that the ileostomy can be closed and the normal activity of the colon is resumed. COLECTOMY. Other patients who undergo ileostomy for acute ulcerative colitis either do not improve or actually continue to become more ill, and die unless further operative procedures are undertaken. For these patients relief from symptoms can be secured by removal of the inflamed bowel; since the entire colon is so commonly involved a total Colectomy is necessary. The re- moval of the entire large intestine is a formidable and hazardous operation, but good results follow careful preparation of the pa- tient and judicious division of the procedure into two more stages. Sometimes the rectum can be spared, and at a later date an anastomosis carried out between the lower small intestine and the rectum; usually this is not possible and the patient must face the future with a permanent ileostomy. Because carcinoma not infrequently arises in the colon of patients who have had ulcera- tive Colitis for a long time, total Colectomy is performed more often than formerly. Nursing Care. The surgical nursing care of the patient should continue without interruption the general supportive care begun on the medical service. As quickly as possible, the nursing staff must learn to know the patient and his response to care. The personality of the usual patient with ulcerative colitis is apt to deviate considerably from the norm. If the patient is permitted to eat he is put on a low residue diet because this minimizes mechanical irritation of the colon. Small, frequent feedings are usually more easily tolerated. Local heat to the abdomen may be indicated. The doctor frequently 302 NURSING IN SURGERY OF THE ALIMENTARY TRACT orders phenobarbital to combat restlessness and iron for sec- ondary anemia. In addition, antibiotics are usually ordered to reduce the bacterial growth in the intestinal tract. A Cantor tube is passed eighteen hours before operation for intubation of the small intestine. All regular preoperative measures for abdominal Surgery are carried out. Total Care of the Ileostomy Patient. Proper indoctrination of the patient should begin before operation, especially if the pa- tient has not yet had his ileostomy. If he already has it, he is acquainted with the problems, although he may yet cherish the wish that it is temporary and will be depressed at the loss of this last hope. It is a grave error to minimize to the patient the diſ- ficulties involved in living with an ileostomy. The proper way to present the subject is as a challenge to the individual. Do not suggest that all will be easy, but tell the patient that management of an ileostomy is a difficult, life-long job and indicate to him that his surgeon and nurse believe that he has the ability and courage to handle the situation. Tell him of others who have surmounted this obstacle and arrange to have the patient, after his own operation is over, meet one or more individuals who are taking good care of their ileostomies. It is also useful to tell the patient that all of the good ideas about ileostomy management have been developed by patients who have ileostomies. The stu- dent nurse will note later in this chapter that a different view is taken of Colostomy management; that is because the management of a colostomy is child's play compared to the constant and har- assing nature of ileostomy management. After operation, the plan for physical care follows that of any postoperative surgical patient. Intravenous fluids are given as needed to maintain adequate intake. Limiting the intake of fluids by mouth will inhibit the tendency of the ileostomy to discharge excessive amounts of intestinal content. Tap water is given to test the tolerance of the patient. If this goes well, a low residue diet is offered. The patient is taught that progression of diet toward normal will depend to some extent upon himselſ. Many foods are tolerated by some without difficulty, while in others they may cause severe diarrhea. The discharge from the ileostomy is at first thin, green and watery, but later it becomes semisolid in ſavorable cases. In all patients, there is a difficult problem of skin care. The abdominal wall must be protected from the irritating intestinal juices. Ab- solute cleanliness is the first step. Every effort should be made to NURSING IN COLON SURGERY 303 FIGURE 86. A, Protruding ileostomy; B, ileostomy bag; C, fitted ring which is ccmentcol to skin. keep the patient's dressings clean and dry. This necessitates changing the dressings frequently, oſten every hour, but at least every two hours, depending entirely upon the individual case. Each time the dressings are changed the patient's abdomen should be thoroughly washed with soap and warm water and dried. After the skin is cleansed, tincture of benzoin may be applied to insure complete dryness and protection. Oſten the application of a medicament such as mentioned on page 271 (duo- denal fistula) will help protect the skin. The patient should be taught to change his own dressings as soon as his physical condi- tion permits. He should be instructed carefully and should be helped many times before making the attempt to change his own dressings. As soon as possible he should be fitted with a bag which is cemented to the skin and which provides a receptacle for the Collection of ſeces. There are several types of bag available at present. Probably the one most commonly recommended is the “Rutzen” bag. There is a flat ring, made to fit closely about the ileostomy, which is cemented to the skin. The bag is cemented 304 NURSING IN SURGERY OF THE ALIMENTARY TRACT to this ring and further supported by a narrow belt about the waist. The cement is readily dissolved by benzine. Because there is no possibility for intestinal juices to come in direct contact with the skin, this bag is especially helpful in preventing excoria- tion. The objective of the nurse during care is to help prepare the patient to resume his place in his family and community. To curb excessive attention to the ileostomy by encouraging him to take part in some diversional or occupational therapy is essential. To guide him in establishing the essential principles of good health habits requires patience and tact. The nurse must learn to give untiringly of her time and effort during this period. Questions are often beyond the responsibility of the nurse; the doctor should be informed about these. The many complexities in the personality and the great emotional instability which is often present bring forth problems which will tax the ability of all. Before discharge of this patient, the complete plan of care at home should be understood by patient and family. Suppor- tive after-care from the social worker or nurse should be pro- vided or continued according to his need. OTHER INFECTIONS Tuberculosis and lymphopathia venereum also cause inflam- matory lesions of the large bowel. Treatment of these is pri- marily medical, but occasionally complications arise, such as perforation or obstruction, which must be dealt with surgically. Diverticulitis. A common disease of the colon which is not pri- marily inflammatory in nature is diverticulitis. This disease usually occurs in patients past middle age. The chronic form is characterized by bouts of griping lower abdominal pain asso- ciated with severe constipation, whereas the more acute ſorm may simulate acute appendicitis. Serious hemorrhage can also occur. In some persons, multiple little outpouchings (divertic- ula) are found in the wall of the colon, particularly the descend- ing and sigmoid portions; whether these diverticula develop as the result of a congenital deſect or as the result of the stress and strain to which the wall is put, is not known. The occurrence of acute or chronic inflammation in these structures is favored by the irritation caused by the collection of fecal material in them. Most patients are successfully relieved of their symptoms by medical means, but occasionally perforation occurs. Peritonitis or a localized abscess follows perforation, depending upon the NURSING IN COLON SURGERY 305 §:3% lºº §§ §§º * tº: §§§ - fº º Y- tºº **. 㺠º 2 *Z &S * Ç & & zººs *. t -er & **** *Gaº y ?, •º assº * $3. ** A & w - - = x-rre-es Ileum FIGURE 87. In tussusception. anatomic position of the diverticulum. Since this disease usually occurs in elderly patients who are not good risks for major surgery, operation in cases of diverticulitis is undertaken only when all other measures have failed. INTUSSUSCEPTION Intussusception is a telescoping of the bowel. One segment or loop of intestine becomes invaginated in the next portion, the process being initiated and continued by waves of peristaltic Con- traction. The commonest site of this mishap is at the junction of the terminal ileum and the cecum. The ileum is sucked up in- to the large bowel until it can go no farther because of the pull on the mesentery. Since the intestinal mesentery is proportion- ately shorter in adults than in infants and young children, adults seldom present this condition. The symptoms are like those of acute mechanical ileus; in addition, the intussuscepted bowel may form a palpable abdominal tumor, and there is usually passage of a bloody stool. Gangrene of the involved intestine quickly de- velops, and intestinal resection may be necessary unless surgical exploration is undertaken within a few hours after the symptoms begin. Frequently the early, mild case may be cured by reducing the intussusception by means of an enema, the fluid entering 306 NURSING IN SURGERY OF THE ALIMENTARY TRACT the colon from below pushing the invaginated bowel back and Ollt. MEGACOLON An occasional infant or young child may develop intractable constipation with progressive swelling of the abdomen. Roent- genologic examination, after introducing a barium enema, will disclose a hugely dilated colon. There is probably more than one cause of this condition (also known as Hirschsprung's disease), but in some patients, at least, it is due to a congenital absence of some of the nerve cells of the colon, so that peristalsis is absent or ineffective. Treatment consists in the removal of the abnormal portion of the colon. VOLVULUS The last portion of the colon, known as the sigmoid because of its S-shaped turns, has in adults a relatively long mesentery. Occasionally this loop of colon, when overfilled or under other abnormal circumstances, may turn or be pulled out of position, with a resulting twisting of its attached mesentery. This twisting or rotation of the mesentery causes occlusion of the mesenteric blood vessels, just as twisting a segment of a rubber tube occludes the lumen. As a result gangrene of the bowel develops. The symp- toms again are like those of acute mechanical ileus. This condi- tion is called volvulus. Obviously, early surgical intervention is necessary to save the circulation of the bowel and the life of the patient. POLYPOSIS OF THE COLON A polyp of the colon is a benign papillary adenoma of the mucosa. Varying in size from the head of a pin up to a marble, this neoplasm may occur anywhere in the large bowel. The deli- cate epithelial covering of the surface of this tassel-like tumor is easily ulcerated, with subsequent bleeding, which is the nature of the patient’s complaint. Polyps may be seen directly on sig- moidoscopic examination, or may be outlined in the x-ray film by a barium enema. Often there are dozens or even hundreds of these tumors in the same individual, producing bloody diarrhea and severe secondary anemia. The most serious aspect of multiple polyposis of the colon is the fact that there is frequently malig- nant degeneration of one or more of the polyps, resulting in can- cer of the colon. Surgical removal of the involved portion of the NURSING IN COLON SURGERY 307 colon is advisable, and sometimes it is necessary to remove the entire colon and rectum in order to cure the patient. CANCER OF THE COLON Affecting men and women of middle age and older, malignant tumors arising from the epithelium of the lining of the Colon are a moderately common type of cancer. These neoplasms may occur at any point from the ileocecal valve to the rectum, and are characterized, like other forms of cancer, by an insidious, painless onset. The symptoms are progressive constipation, abdominal distention, loss of weight, and passage of small or large amounts of blood in the stool. Sometimes the tumor can be palpated through the abdominal wall, or observed through a sigmoido- scope. The diagnosis is usually made, however, by x-ray examina- tion during the administration of a barium enema. It is fortunate that many cancers of the colon are relatively slow to metastasize, so that surgical cure can be accomplished. These tumors do not respond well to radiation therapy, and the modern method of treating them is to excise the portion of bowel containing the tumor, together with the adjacent portion of the mesentery. Whenever possible, the continuity of the colon is re- stored, but in many instances this is not feasible, so that the pa- tient must be left with a colonic opening in the abdominal wall (colostomy). Since the colon always contains a large population of pathogenic bacteria, operations upon it are attended by serious danger of infection. Recent advances in preoperative preparation, chemotherapy, antibiotic therapy, and surgical technic have combined to lessen this danger, so that an encourag- ing number of Cures are now being accomplished. PREOPERATIVE CARE Enema Administration. Almost every patient who is thought to have disease of the colon is subjected to x-ray visualization of the colon; many are directly examined by means of a sigmoido- scope. Proper results can be obtained from these methods only if the bowel has been as thoroughly emptied as possible, for gas and feces distort the x-ray picture and interſere with visual ex- amination. Prior to these examinations the patient should be prepared by the administration of a soapy enema the night before, and again early in the morning. Many of these patients have some degree of mechanical ob- struction; the colon above the tumor is apt to be distended and 308 NURSING IN SURGERY OF THE ALIMENTARY TRACT filled with fecal material. This can sometimes be successfully treated by the use of mild saline cathartics and daily enemas for a period of several days; in other instances it may be necessary for the surgeon to establish an opening into the bowel above the obstruction. This is done not only to relieve the obstruction, but also to permit the colon to return to a more normal size and state of health, a most important consideration in the carrying out of the necessary surgical procedures. * Dief. It is also of great help to place the patient on a low- residue diet, thus reducing the bulk of the feces. A sample menu follows: BREAKFAST LUNCH SUPPER Fruit juice (100 cc.) Strained soup Broiled steak Soft boiled egg Baked fish Rice Toast (1 slice with butter) Baked potato Sieved beets Cereal with milk and sugar Sieved peas Bread (1 slice with butter) Coffee or tea Bread (1 slice with butter) Milk (200 cc.) Milk (200 cc.) Canned peaches Ice cream Meat should be lean but need not be ground. Eggs may be served any style except fried. Liver should be given at least once a week. Milk should be boiled three minutes, and the total amount should not exceed one pint in twenty-four hours. Fruits are limited to small amounts of juices, canned pears and peaches, and ripe bananas. All vegetables are sieved. Only white or plain rye bread is used. Refined or sieved cereals are used. Pudding, ice cream, gelatin, cake, and custard are satisfactory, provided they do not contain fruit or nuts. Antibiotic and Drug Therapy. The number of pathogenic bac- teria in the feces may be remarkably lowered by the use of anti- biotic agents (streptomycin, aureomycin, Terramycin, neomycin) or drugs (Sulfasuxadine, Sulfathaladine). When possible, one of these agents should be given to the patient prior to colon surgery in order to lessen the danger of postoperative infection. Neo- mycin is the most rapidly acting of these agents, and will even be effective when instilled into the open bowel during operation. Infesfinal Intubation. Preoperative intestinal intubation and deflation facilitate the performance of colon surgery and Com- pletely avert postoperative distention and “gas pains.” Twelve to eighteen hours before operation, a Miller-Abbott or a Cantor tube is introduced into the stomach through the nostril, and encouraged to pass the pylorus and travel down the small in- testine. When the tube has progressed nearly to the cecum, it is prevented from further movement by fastening with adhesive NURSING IN COLON SURGERY 309 FIGURE 88. Left, Cecostomy; right, colostomy. strapping to the cheek. Gentle suction is then begun. The tube is irritating to the nose and pharynx, but patients readily put up with this mild annoyance when they are told that the tube will not only make the operation more safe but will also prevent much postoperative discomfort. OPERATIONS ON THE LARGE INTESTINE Colosfomy. Colostomy, the establishment of an opening of the bowel through the abdominal wall, is carried out at nearly any point along the colon; the common sites, however, are the cecum (cecostomy), the transverse colon, and the upper portion of the sigmoid colon. The desired portion of the bowel is delivered through a small wound, and is held out on the surface of the abdomen by means of a gauze sponge, a cigarette drain, or a clamp, no sutures being placed in the bowel. As there are multi- tudes of pathogenic bacteria in the lumen of the large intestine, the bowel is not opened for forty-eight to seventy-two hours; this delay permits the wound about the colon to become sealed off and thus prevents infection of the deeper tissues and peritoneal 310 NURSING IN SURGERY OF THE ALINMENTARY TRACT A * §§ à. 3 Ş ? º 3. & º Sºs º º ſº ºğ ſ ſº w § ſº % ºğ | º §§§ § % | ſº Sºğ. *% º ºv. Wºº º % ºft sº Y º iº s - º FIGURE 89. Exteriorization resection of colon. A, The diseased segment is ex teriorized, B, Resection of the exteriorized segment, using the actual cautery. C, Reestablishment of continuity by crushing the spur between the approximated ends of the colon (side view). cavity. An opening is then made with scissors or cautery while the patient is in the ward; no anesthesia is necessary. If the patient is unable to withstand obstruction for this period, a tube may be inserted earlier, and flatus allowed to escape. Resection. The operative removal (resection) of the different parts of the large intestine is carried out according to certain rules which have been established by surgical experience. It has been found safer to remove the entire cecum and ascending colon (right colectomy), even though the lesion may involve only a small portion of those structures; the continuity of the intestinal tract is reestablished by performing an anastomosis between the terminal ileum and the transverse colon (ileocolostomy). In deal- ing with the transverse and descending colon, however, it is tech- nically feasible to resect only the involved segment; when this segment is not too long, it is often possible to reestablish con- tinuity by direct anastomosis of the remaining ends of the bowel. NURSING IN COLON SURGERY 31 I In the past, because of the danger of infection, an alternative technic was devised which made use of the principle of ex- teriorization. At operation the diseased segment of intestine with its mesentery was mobilized, brought through the wound, and placed outside the abdominal wall, the efferent and afferent loops of bowel being carefully approximated as they passed through the wound (see Fig. 89). Two or three days later the exteriorized segment of bowel was resected, leaving two open ends of bowel at the skin edge of the wound. At a later date the resultant colostomy could be closed. This type of resection is still employed when the patient's condition or the nature of the lesion so requires. Total Colectomy. Total colectomy is usually performed in two or three stages. At the first operation a permanent ileostomy is established and, if the patient's condition permits, the right half of the colon is resected. The second operation, two to six weeks later, consists in removal of the transverse and descending por- tions of the colon. At a third sitting, after a suitable interval, the sigmoid colon and rectum are removed in the manner to be de- scribed under the treatment of cancer of the rectum (abdomino- perineal resection). NURSING CARE AFTER OPERATION All that has previously been stated with regard to the general postoperative care of patients who have undergone laparotomy applies to those who have had surgery of the colon. There are also certain additional features. Suction drainage through the inlying tube is continued until active peristalsis is restablished, as evidenced by audible bowel sounds and the passage of flatus. Following the removal of the Miller-Abbott or Cantor tube the patient should be kept on a liquid or a low residue diet until healing is complete. Laxatives and cathartics are forbidden, but mineral oil is used when encouragement of defecation becomes desirable. The use of enemas is not permitted at first, but after healing has progressed well, small enemas may be used to induce defecation. If the anastomosis is well above the rectum, the rectal tube may be used to aid in passage of flatus; oſten, when the suture line is near the rectum, a tube is placed through the anastomosis from the rectum in order to permit constant escape of flatus. Should the tube become dislodged, however, it must be replaced only by the surgeon. 312 NURSING IN SURGERY OF THE ALIMENTARY TRACT Core of Patient with Colostomy Before the nurse accepts the responsibility for the nursing care of a patient with a colostomy, it is desirable that she have some understanding of the physical and psychologic aspects of the condition. She must develop the proper attitude herself before she can be of real help to a patient. It has frequently been stated that the patient's abhorrence of a colostomy may be readily overcome. This seems, however, not to be as easy as once was advocated. It has been found that there are numerous factors which enter into the physical and psychologic adjustment. The manner in which the patient will react to his entire hospital experience will depend on his fear of operation, death, incapacitation following operation and subse- quent social rejection. His reaction will depend to a great extent on the adaptations he has made to living before the onset of his illness. His reaction to this severe stress brings forth many of his fundamental emotional convictions. It is at the time of the onset of symptoms that most patients begin to experience fear; this gradually progresses until a crisis is reached. The greatest stress seems to be evident around the time of surgery. The following recommendations are directed toward helping the nurse care for a colostomy patient and are based on objec- tives which are fundamentally positive in Orientation. They are: 1. The nurse must know the details of the plan of care. 2. She must establish good rapport. Confidence generated by an understanding interest in the patient and his family is essential. 3. The nurse who is best known to the patient should accom- pany him to the operating room. 4. She should accept without argument any expressions of resentment by the patient. They give evidence of his de- sire to live and resume his place. If the patient is per- mitted to express his resentments, resolution will be more apt to take place. 5. The patient should be encouraged to talk, and when the nurse becomes aware of ſears or anxiety these should be noted and reported to the surgeon as soon as possible. 6. When instruction for irrigating the colostomy begins, all members of the team should know exactly what is going to be done, and what progress is being made. This plan of care should be outlined and recorded. Any inconsistencies NURSING IN COLON SURGERY 3.13 10. 11. or uncertainties are very detrimental to acceptance and learning on the part of the patient. The nurse assumes the responsibility for teaching the patient; she should be aware that teaching and telling are not the same. . She should be aware of the great variance in ability to learn on the part of different patients; that the first look at the colostomy by the patient is a shocking experience to him. Refusal to learn, which is often exhibited, may not be willful but can be evidence of anxiety and depression. Understanding, patience and kindness are the important attributes which are significantly helpful in resolving his WOICICI6S. The nurse must have a positive attitude toward cleanli- mess, ſeces and disfigurement. The attitude of the patient concerning these must not be permitted to reflect negative feelings on the part of the nurse. A negative attitude will not only retard learning but will actually be destructive to the ability of the patient to function in all areas of living. It may be stated that gesture and tone often reveal the nurse's attitude as much as or more than her words. . The nurse should encourage the patient to have a part in the plan of procedure of irrigations. However, a tendency for him to focus too much attention upon the procedure is a warning signal. She should direct his thinking to pre- vent this treatment from becoming the focal point of all his activity. She should encourage the patient to accept the support of his family. His ability to talk to them freely will encourage the rapport that was in existence before he became ill. If the nurse has the continued confidence of the family she is in good position to influence their acceptance of the patient. When the patient goes home, it is highly desirable that someone besides the patient understands his care and aids him in bridging the gap between hospital and home. The person for this may be a nurse or a member of the family. If it is a nurse who has not known the patient previously, she should get the information on the details of care before she goes into the home. These would include what the pa- tient knows about his illness as well as what self-care he has been able to carry out in the hospital. When it is a 314 NURSING IN SURGERY OF THE ALI MENTARY TRACT member of the family who is to help, instructions and demonstrations in the care of the patient should have been carried out in the hospital. 12. Lastly, the nurse should rehearse with the patient the plan of follow-up care which the surgeon has planned and, in addition, strengthen his security by assuring him of the willingness of the surgeon to see him if he has any ques- tions or worries. The type of colostomy referred to here is a permanent one, usually established in the sigmoid Colon; regular evacuation of the feces from the bowel is initiated by irrigation. The aim in treatment is to create a “dry” colostomy: one where spillage does not occur during the interval between the daily mechanical cleansing of the bowel. In considering the patient with a temporary colostomy, every- thing that has been said also applies but there is usually less severe emotional stress because the patient has the hope, from the onset, of the closure of the colostomy with subsequent normal bowel function. However, if such a patient did not know how to care for himself in the best possible manner, the colostomy would become a barrier between him and his family and so- ciety. It is this type of patient who frequently denounces the colostomy to his friends and relatives because of his inability to function in his former areas of living. Whenever the patient has a colostomy which is a palliative measure for an incurable cancer, he is usually in the terminal stage of his illness. This time may vary from a few months to years, depending on the virulence of the malignancy and the extent of the growth. The colostomy in such patients is often in the transverse colon; in this location irrigations are not entirely successful in preventing accidents. It is this variety of patient who needs much physical care as well as emotional support in order to make him as comfortable as possible. When a colostomy has been performed, the dressing of the pri- mary abdominal wound is usually sealed with collodion or Whitehead's varnish. Sterile petrolatum gauze is placed on the skin and around the colostomy loop, which is then covered with gauze dressings held in place with adhesive plaster or a scultetus binder. When the colostomy is opened by the surgeon, on the second or third day after operation, there is often an evacuation of liquid stool. Additional preparations must therefore be made. A rubber NURSING IN COLON SURGERY 315 sheet covered with a towel should be placed crosswise between the patient and the draw sheet. A curved basin is placed against the side of the patient for collection of the feces. The surgeon orders irrigations once or twice daily The amount of solution varies from 250 to 1000 cc. depending upon the length of colon remaining. The purpose of the irrigation is to cleanse the intestinal tract of feces, gas and mucus, to prevent intestinal obstruction, and to establish regularity of evacuation. In many clinics nurses carry out this treatment. The time selected to carry out the procedure depends on when it is convenient, but should be about the same time each day. However, this does not mean that this is the time when the patient must carry out the procedure when he returns home; he should plan to do it when it is most convenient at home. Each day there should be a demonstration with careful explanation and teaching suited to the ability and acceptance of the patient. Refusal to look at the colostomy at first should be accepted; too much explanation should not be made lest the patient feel he is being forced. Each patient must be carefully evaluated. Individ- uals do not react the same, they do not learn with the same rapid- ity and the nurse each day must accept her patient according to his changing ability. The nurse must guard against the fact that sometimes the patient will carry out the procedure because he wishes to win her approval rather than a desire for independent and free self-care. The equipment suggested for an irrigation is the same as that used in giving an enema. In addition, several curved basins, a dressing basin lined with newspaper, dry and boric acid sponges and gauze dressings are necessary. The solution used may be tap water, normal saline solution, or soap, heated to 108° F. The irrigation pail is adjusted so that the fluid is 18 inches above the Colostomy opening. After the dressings have been removed and placed in the newspaper in the basin, the colostomy area should be cleansed with boric sponges if the skin is soiled. A curved basin is then placed against the side of the patient to col- lect the return fluid. The rectal tube should be gently inserted 6 to 8 inches; the solution is allowed to run in ahead of the tube to distend the colon. Occasionally after the introduction of the tube it seems to meet a temporary obstruction: this is a natural Contraction of the intestine which will relax in time. Another curved basin may be held over the opening to direct any sudden gush of fluid. Complete emptying of the bowel requires from 316 NURSING IN SURGERY OF THE ALIMENTARY TRACT twenty to fifty minutes. Slow evacuation of feces and gas may be hastened by turning the patient from one side to the other. This may always be resorted to when the patient is uncomfortable because of distention. There is other, more elaborate equipment which can be ob- tained for colostomy irrigation. The patient should be encour- aged to try various types of irrigators until he discovers which permits easy administration of an irrigation. Another aspect of care which can be varied is the amount of solution used. The pa- tient is often told that he may use as much solution as is needed until he feels that all feces have been evacuated. This statement should be qualified by the explanation that there is no advantage to excessive irrigation; it is undesirable for a patient to focus too much attention upon the irrigation and develop a Compulsive practice. There is a difference between an enema and an irriga- tion; in the enema the solution is placed into the gut and peristalsis then causes evacuation, whereas in the irrigation the 1ecal material is washed out by means of large amounts of Solution and peristalsis. Some patients, following permanent sigmoid Colostomy, are able to evacuate feces daily through their colostomy without ir- rigation or enema. The Colostomy in these is situated at the lower end of the midline laparotomy Incision. They sit on an ordinary toilet, lean slightly forward and evacuate their ſeces directly into the bowl. Usually these patients learn quite by accident, after receiving the usual Instruction and after carrying out the enema procedure, that peristalsis and evacuation are possible without an introduction of solution into the intestine. It seems apparent that the psychologic aspects are extremely closely allied to the physical functioning. Sometimes the Colostomy consists of two openings, that of the proximal and that of the distal segment of colon. At times it is necessary to clean the distal bowel because of the accumulation of mucus. This may be done immediately after the irrigation of the proximal loop. After the patient has been placed on a bedpan, the ordered solution should be introduced into the distal loop through a rectal tube. When there is an obstruction the fluid should be siphoned off. In such an instance, the bowel below the obstruction may be cleansed by giving a small enema through the anal Canal. Following the irrigation the Colostomy area should be washed with soap and water. An appropriate dressing is then applied to NURSING IN COLON SURGERY 317 protect the colostomy and to collect any fluid or feces. The first few days after the colostomy has been opened, fecal material often flows freely so that the soiling and the odor are offensive. Changing the dressings according to the need and washing the area will make the patient, and all those around him, more Com- fortable; this also protects the skin against any excoriation which may occur if the fluid is permitted to remain on the ab- dominal wall. Following operation, the patient is usually continued on suc- tion drainage through the Cantor tube so that oral feeding is not possible. After removal of the tube, the patient is given liquid diet, and this is increased as tolerated with the emphasis on Con- stipating foods. In some clinics, a rigid constipating diet is given while, in others, the patient is advised to eat according to his own wishes. The patients often have strong feelings concerning ſoods. They believe that some cause diarrhea and increase the danger of spillage. The important things for the nurse to teach to the patient are the components in foods which are essential, and the various foods which contain these within the limits of his diet. After ten or twelve days the colostomy is usually regulated ſairly well. Some surgeons order a colostomy bag to be worn until the patient feels secure without one. Others believe that the patient should not be given a bag because it might weaken his faith in the colostomy regulation. It may be said that when a patient has an “unfavorable” colostomy, as in terminal can- cer, it is often very desirable ſor the patient to wear a bag be- cause it permits him to be out of bed without the apprehension of soiling his clothes. There are various types of bags, some made of disposable synthetic materials, which are placed over the Colostomy and fit snugly against the abdomen when the straps are adjusted. Before the patient leaves the hospital he should be able to care for himself fairly well unless he has a terminal illness. Instruc- tions, as was stated before, are begun as soon as possible and pro- ceed at the rate the patient can accept them. Repetition in teach- ing is the rule, not the exception. Equipment for home care should be like that used in the hospital. It is helpful to furnish patients with printed instructions. It is advisable that someone who knows how to carry out the procedure be in the home with a patient when the latter first irrigates himselſ. Iſ the nurse who is going to do this can visit the patient in the hospital, the carry- 3.18 NURSING IN SURGERY OF THE ALIMENTARY TRACT over of teaching and the confidence and security of the patient are reinforced. If it is a member of the family, they should have had patient and thorough instructions during which they have evidenced a sincere desire to help the patient in a positive, un- pitying manner. The satisfaction of sending a patient home who is able to care for himself and who believes he can resume his for- mer activities in his home and society is rewarding to all those who have had a part in helping him in the adjustment. SUMMARY Lesions of the colon, especially cancer, are common and are often amenable to surgical therapy. Decompression of the in- testines by intubation and suction, and the reduction of the bac- terial content of the colon by modern antibiotic therapy make colon surgery safe. Ileostomy and Colostomy are ſrequent sequels of Colon surgery; ileostomy care is a Constant challenge to the pa- tient and nurse, whereas colostomy care is relatively simple. VOCABULARY REVIEW colectomy megacolon ileocolostomy diverticulitis cecostomy polyposis intussusception irrigation volvulus peristalsis SUGGESTED READING 1. Cancer Nursing. National Cancer Institute and N. Y. Dept. of Health, 1950, pp. 44–47. 2. Dennis, Clarence: Ileostomy and Colectomy in Chronic Ulcerative Colitis. Surgery, 18:435–451 (October) 1945. 3. Lahey, Frank H.: Indications for Surgical Intervention in Ulcerative Colitis. Ann. Surg., 133:726–741 (May) 1951. 4. Presman, D.: 'A New Method of Skin Protection for Ileostomies and Colos- tomies. Surgery, 13:322 (February) 1943. . Friedman, M. H. F.; Aluminum Hydroxide Gel for Erosions in Patients with Bowel Fistulas. J.A.M.A., 131:520–521 (June 8) 1946. 6. Sutherland, Arthur: The Psychological Impact of Cancer and Cancer Sur- gery. Cancer, 5:857–872 (September) 1952. 5 CHAPTER 28 Nursing in Proctologic Surgery The special field of proctology includes the diagnosis and treat- ment of lesions of the rectum, anus, and perineum. Anatomy and Physiology. The rectum, the terminal segment of the alimentary tract, lies wholly outside the peritoneal cavity, and is in intimate relationship with the bladder, seminal tract, and prostate gland in the male, and with the posterior wall of the vagina in the female. The muscular coat is thicker than that of the remainder of the large intestine. The anus is the outlet of the tract; except during defecation and expulsion of flatus, it is kept tightly closed by the action of the strong, circular muscles of the anal sphincter. The rectum and anus are supported by the mus- cles of the perineum as well. The glandular epithelial lining of the rectum (rectal mucosa) is replaced, just within the anus, by the squamous epithelium of the skin, which is continuous with that of the perineum. Distention of the rectum by feces or flatus produces the normal desire to defecate, and defecation is accomplished by expulsive Constriction of the rectum occurring simultaneously with relaxa- tion of the anal sphincter. The expulsive effort is aided by con- traction of the abdominal and perineal muscles, thus increasing the intra-abdominal pressure. The act of eating stimulates in- testinal peristalsis; this, in turn, acts to propel feces and gas into the rectum, and, as a result, the desire to defecate usually follows the ingestion of a meal. Anything that irritates the rectal mucosa also produces the desire for defecation; included in this category are irritating chemicals, fluid stools, and any type of ulceration of the rectal mucosa. The desire to go to stool, felt urgently and frequently (tenesmus), is a symptom of rectal irritation. Constipation, which can be defined as inadequate emptying of the bowel, is largely a medical problem, but has many surgical aspects nonetheless. Obviously, mechanical obstructions produce Constipation; it is important to know, however, that often very minor inflammatory lesions of the rectum or anus can sufficiently interfere with the normal function of these structures to produce constipation, or to greatly increase habitual constipation. 3.19 320 NURSING IN SURGERY OF THE ALIMENTARY TRACT Methods of Examination. The patient may be placed in the lithotomy position, in the Sims' lateral position, or in the knee- chest position; the first two are more comfortable for the patient, but the knee-chest position permits the most adequate examina- tion of the perineum, anus, and rectum. Following inspection of the perineum and anus, a digital rectal examination is made. For this a rubber glove or a rubber finger cot, coated with petrolatum or lubricating jelly, is used. Proctoscopy. Additional information is gained from direct in- spection of the rectal mucosa by means of a proctoscope. This is a short tube of suitable caliber, fitted with a blunt stylet which is removed as soon as the instrument has been passed beyond the sphincter. The proctoscope must be well lubricated, and should be warm. Some instruments are fitted with electric illumination, which is more satisfactory than a flashlight or head mirror. The proctoscope is passed upward under direct vision. Under ideal conditions it is possible to examine by this means, or by using a longer tube (sigmoidoscope), the lower 10 or 12 inches of the alimentary tract. A satisfactory examination of this sort can be made only if the bowel contains no feces, and therefore these pa- tients must be prepared shortly before examination by the ad- ministration of a cleansing enema. Fluoroscopy. An additional means of examining the rectum and lower sigmoid colon is by use of the barium enema. The pa- tient is previously prepared by cleansing enemas. He is then placed on the fluoroscopic table and a barium solution is care- fully injected into the rectum; the filling of the bowel is visualized on the fluoroscopic screen or by means of x-ray films. FECAL INAPACTION An occasionally overlooked but simple cause of Constipation is a mechanical obstruction of the lumen of the rectum due to the accumulation of hard, dry feces. This occurs in inſants, and some- times in adults who have been careless about elimination. Diag- nosis is made by the discovery of the hard mass of impacted ſeces on digital examination of the rectum. A soap or an oil enema may soften the ſeces sufficiently to permit expulsion, but at times it is necessary for the surgeon to break up the impacted feces with the finger. This Condition is also a Complication of injury or disease of the central nervous system; thus, paralyzed patients, who have lost the ability to move the bowels readily, develop im- pactions unless cleansing enemas are regularly administered. NURSING IN PROCTOLOGIC SURGERY 32] FISSURE IN ANO Rectal fissures are in reality small ulcers of the rectum, occur- ring at the mucocutaneous junction. This lesion is one of the most painful of rectal Complaints, the pain characteristically occurring during and immediately after defecation. The cause of anal fissures is not known. The ulcer tends to become chronic, and usually surgical excision is necessary to accomplish healing and Cure. Sometimes local applications, the use of mineral oil to soften the ſeces, and digital dilation of the sphincter suffice to bring about healing. ANAL PRURITUS Another extremely distressing rectal complaint is intractable itching of the anus and adjoining skin. This is caused at times by a fissure, or by eversion of the rectal mucosa with consequent secretion of mucus, but more often no pathologic condition of the anus is apparent. The incessant itching usually leads to irritation and excoriation of the perineal skin because the patient cannot refrain from scratching; indeed, many of the patients have been observed to scratch during sleep. The cure is accomplished by remedying any pathologic Condition of the rectum that can be ſound, and by local measures designed to decrease the itching and hence the scratching, thus permitting the irritated skin to heal. The application of alcohol, the use of cold baths, and keeping the perineum shaved and dry will alleviate the milder cases, but often it is necessary to anesthetize the perineal skin temporarily. This is accomplished by the careful subcutaneous injection of minute amounts of 95 per cent alcohol. HEMORRHOIDS The rectum is richly supplied with veins (hemorrhoidal veins), and, as a result of man's upright position and the increased pres- sure incident to straining during deſecation, dilatation of these Veins is common. A hemorrhoid is a dilated vein, situated imme- diately beneath the rectal mucosa or skin of the anus, and is Com- parable to a varicose vein in the leg. External hemorrhoids are those occurring outside the sphincter, beneath the anal skin; internal hemorrhoids are those occurring within the rectum. | Symptoms. There is scarcely a person who goes through life without experiencing in some degree the symptoms of hemor- rhoids. These symptoms are bleeding, pain, and protrusion, occurring singly or in all possible combinations. Of course con- 322 NURSING IN SURGERY OF THE ALIMENTARY TRACT stipation usually accompanies hemorrhoids when defecation is painful or when it is feared that the act may cause pain, and naturally constipation, by increasing the difficulty of defecation, aggravates the hemorrhoidal condition; thus a vicious cycle is initiated. External Hemorrhoids. The common symptom is the sudden appearance of a painful little mass just at the amus, due to the thrombosis of the involved branch of the hemorrhoidal vein. Internal Hemorrhoids. The common symptom of these is bleeding, which may range from a few drops seen on the toilet paper to 50 or 100 cc. of blood lost with every defecation. Pain does not commonly occur with internal hemorrhoids, but pro- trusion through the sphincter is frequent. In severe cases large internal hemorrhoidal masses may become ulcerated, the veins may thrombose, and the whole swollen mass may prolapse through the sphincter, causing severe pain. Diagnosis. External hemorrhoids are diagnosed upon inspec- tion of the anus, but internal hemorrhoids, unless prolapsed, can be seen only on proctoscopic examination. Since there are many causes of rectal bleeding, careful direct examination of the rec- tum must be made in every case in which bleeding is a symptom. Treatment. External Hemorrhoids. The pain and swelling due to thrombosis of an external hemorrhoid subsides in three or four days, so that treatment is necessary only to make the patient more comfortable. Local application of anesthetic drugs (anodynes), mineral oil, and warm sitz baths are useful; also the patient will feel better if he restricts his activity, avoiding lifting or other strenuous work. Internal Hemorrhoids. These, however, usually require more aggressive treatment. In mild cases the use of mineral oil by mouth and the local application of suppositories or ointments which contain astringents to shrink the rectal mucosa, suffice to relieve the patient's symptoms. When there is persistent bleeding, or when prolapse and ulceration occur, surgical treatment is re- quired. Some surgeons prefer to treat hemorrhoids by the injec- tion of sclerosing solutions, as in treating varicosities of the legs. Others prefer to excise the hemorrhoids (hemorrhoidectomy). ISCHIORECTAL ABSCESS In view of the nature of the contents of the rectum it is not surprising that inflammation and ulceration of the rectal mucosa sometimes occur, and at times virulent bacteria penetrate NURSING IN PROCTOLOGIC SURGERY 323 through the rectal wall into the tissues outside. There is consid- erable fat and loose connective tissue in the ischiorectal spaces, permitting the formation of large abscesses. Symptoms. Such an abscess is situated deeply at first, and there may be little in the way of external signs. The patient complains of severe, throbbing pain about the rectum, and cannot sit Com- fortably; later there is increasing constipation and the usual systemic accompaniments of infection, including fever, malaise, and leukocytosis. The perineum overlying the abscess is tender, and late in the disease redness and induration occur. Rectal ex- amination may be impossible before the patient is anesthetized, owing to the exquisite tenderness, but when such examination is made the abscess can be palpated. Treatment. An ischiorectal abscess must be incised and drained as soon as possible to prevent further spread of the infection. It is essential to secure adequate drainage and, therefore, good ex- posure and relaxation are needed, usually requiring general anesthesia. The abscess cavity is often large, containing much ſoul-smelling pus. Following drainage the patient improves very rapidly, and is quite comfortable within a day or two. FISTULA IN ANO Sometimes complete healing follows the prompt drainage of an ischiorectal abscess, but more Commonly healing progresses until only a small draining sinus remains. Such a persistent draining sinus, which communicates with the old abscess cavity and hence with the lumen of the rectum, is a fistula in ano. This is a chronic lesion, and over many months or years it will not only fail to heal, but is likely to spread, forming other intercom- municating openings. Eventually multiple openings may form all around the rectum and perineum, each draining Small amounts of pus; this is called a “watering-pot” perineum. One may wonder why a patient will permit such a lesion to go on and on; actually there is little pain or discomfort, and the drainage seems not to be very annoying to the less fastidious. It is the communica- tion with the rectum which causes the fistula to persist, because a little flatus or fecal material is squeezed into the infected tract from time to time. Treatment. In order to cure a rectal fistula it is necessary to lay the tract wide open into the rectum, dividing the sphincter. The large shallow wound resulting from this maneuver is permitted to heal from the bottom up, care being taken to prevent the skin 324 NURSING IN SURGERY OF THE ALIMENTARY TRACT edges from coming together until the deeper tissues have filled in. The patient is temporarily incontinent of feces after division of the sphincter, but if the sphincter is divided in only one place it nearly always heals with complete return of function. When mul- tiple fistulous tracts are present it is usually not possible to re- move them all at one sitting, as the resultant defects might lead to permanent incontinence. Such patients are best treated by excision of the fistulous tracts in two or more stages, which per- mits the sphincter muscle to heal and regain its function between each operation. RECTAL INCONTINENCE; IMPERFORATE ANUS Congenital maldevelopment of the rectal sphincter, or severe damage to this important muscle caused by disease or injury, permits the anus to remain open with consequent uncontrollable discharge of feces, flatus, and mucus. A plastic operation, in which a sling of fascia that can be controlled by contraction of the gluteal muscles is placed about the rectum, has been success- ful in restoring anal control to many patients who have had this most distressing condition. An occasional infant, on the other hand, is born without an anal opening. This, of Course, Con- stitutes an acute surgical emergency to relieve the Complete mechanical obstruction. In some instances it is only necessary to puncture a diaphragm of skin, but in others the lower portion of the rectum and the sphincter are absent or poorly developed, making the establishment of a normal anus often difficult or im- possible. LYMPHOPATHIA VENEREA The close anatomic relationship and the lymphatic drainage of the vagina and rectum result in frequent involvement of the rectum in lymphopathia venerea. This venereal disease is caused by a virus and is contracted during sexual intercourse with an infected person. It occurs chiefly in Negro women. The infection produces a chronic, granulomatous lesion, with ulceration during the acute stage; later, when healing occurs, there is formation of heavy scar tissue. Scar tissue always has the tendency to contract, and the result of this process in the rectum is a gradual progres- sive constriction of the lumen (rectal stricture). Symptoms and Diagnosis. Lymphopathia of the rectum causes rectal pain and bleeding, discharge of pus, and progressive con- stipation. Diagnosis is established by the clinical appearance of NURSING IN PROCTOLOGIC SURGERY 325 the rectum, and by a positive reaction to the intracutaneous in- jection of the Frei antigen. Treatment. No specific therapy has yet been developed for this disease. Antibiotic therapy (aureomycin) is useful in the acute stage as it helps to reduce the amount of secondary bacterial in- fection. A useful rectal lumen can usually be maintained by means of regular dilation with soft rubber dilators (bougies). This must be done very carefully, and for long periods. In severe cases, however, a colostomy may be necessary in order to relieve the obstruction. NURSING CARE IN RECTAL SURGERY General Measures. In general, the nursing care of patients who have undergone rectal surgery is much the same, no matter which condition has been treated. Despite the contamination of the wound with feces, healing proceeds very well, perhaps an in- dication of the local tissue resistance to the bacteria which are habitually present. Immediately after operation, of course, the patient is observed for signs of hemorrhage; this is especially im- portant after hemorrhoidectomy. Most patients have severe pain after rectal surgery, and large doses of morphine or other opiates are necessary during the first twenty-four hours. Preparation for Defecation. The patient is encouraged to re- frain from defecation for forty-eight to seventy-two hours after operation, in order to lessen to some extent the bacterial con- tamination as well as to avoid undue strain on the wound. Mineral oil by mouth and liquid or other low residue diet are given to minimize the difficulty of defecation. On the third eve- ning after operation it is the custom of many surgeons to order a rectal instillation of mineral oil which is to be retained if pos. sible. This is followed the next morning by the administration of a cathartic (magnesium sulfate or Rochelle salts); defecation is then initiated since the stool has been made as soft as possible. After the bowels have moved well the patient is permitted to have a regular diet. Digital dilation of the rectum relieves painful spasm and prevents the formation of postoperative stric- ture. Moist Heat. The most helpful therapy, however, is the applica- tion of moist heat, including Compresses, irrigations, and sitz baths. These have the effect of cleansing the region and relaxing spasm, thus reducing both the degree of inſection and the severity of pain. 326 NURSING IN SURGERY OF THE ALIMENTARY TRACT { qt sºlº.’ *-------- t |s 40 £:Tiºj $-----> A T CA) QS <2* Y — FIGURE 90. Pattern for modified T binder for perineal dressings. |*H* FIGURE 91. Chair for sitz bath; note that the chair is grounded (wire at A) to prevent electrical hazard from faulty heating unit. NURSING IN PROCTOLOGIC SURGERY 327 COMPRESSES. Hot moist dressings may be applied after the compresses or gauze dressings have been wrung out of the ordered solution heated to 125° F. The moisture and heat will be re- tained when they are protected with a piece of plastic material. They may be held in place with a modified T binder. IRRIGATIONS. Convenient equipment to administer perineal ir- rigations consists of a sterile bottle Containing an Asepto Syringe. The irrigations usually are given twice daily and after defecation. Excess moisture after the treatment may be sponged off with gauze or Cotton. SITZ BATHS. The sitz bath, which derives its name from the Ger- man word meaning seat, is taken in a sitting position. In many clinics a specially constructed tub is available to seat the patient so that only the hips are immersed in water; however, an ordinary bathtub half full of water is suitable for the treatment. The tem- perature of the water is gradually increased from 110 to 120° F. Care must be taken that the temperature does not exceed this last because a burn would result. The patient sits in the water from ten to fifteen minutes. The treatment should be terminated iſ the patient becomes exhausted before the prescribed period of time is ended. The application of a cold compress to the forehead adds to the comfort of the patient. NEOPLAST:C DISEASE OF THE RECTUNA Rectal Polyposis The benign adenoma of the rectal mucosa (rectal polyp) is a common lesion. The symptoms of rectal polyposis include bleed- ing, mucoid discharge, and sometimes protrusion of the polyp through the anus. Polyps may be single or multiple, and may be on a pedicle (stalk) or may have a broad base. Their size varies from pinhead to that of a small lemon. A rectal polyp may be removed by excision or by fulguration with electrocautery. There is, however, a high incidence of malignant degeneration in these polyps, so that microscopic examination of the polyp should al- Ways be made. Corcinomc of the Rectum The rectum is one of the more common sites of cancer. It is fortunate that this lesion produces symptoms relatively early, and that metastasis as a rule occurs but slowly, so that many patients can be cured. Although more common in men of middle 328 NURSING IN SURGERY OF THE ALIMENTARY TRACT age, cancer of the rectum occurs in both sexes and in both young and old. Symptoms. The appearance of blood in the feces should lead to prompt examination of the rectum. In most instances the cause of such bleeding will be found to be due to hemorrhoids, but cancer should always be suspected and searched for. Later in the disease tenesmus and constipation occur, and finally anemia, loss of weight, weakness, and progressive intestinal obstruction. Pain is not apt to be a symptom until invasion of structures outside the rectum has taken place. Treatment. Many operations have been devised for the cure of rectal cancer; of these the most satisfactory at present is the ab- dominoperineal resection (Miles operation). This operation is used in the treatment of lesions of the lower sigmoid Colon as well. The patient is prepared for operation in the manner already described in connection with surgery of the colon (p. 307). Technic of Miles Operation. Through a low midline abdom- inal wound the abdomen is explored to determine the operability of the lesion. The next step is division of the sigmoid Colon. The upper end of this divided colon is brought out onto the ab- dominal wall, forming the terminal colostomy which will be a permanent one. The lower portion of the sigmoid colon is freed from all its attachments, as is the rectum; these structures are left beneath the peritoneum of the pelvic floor and the abdominal wound is closed. The patient is placed in either the lithotomy or Sims' lateral position, depending on the surgeon's preference. A circular incision is made around the anus, and the anus and rectum are freed from their attachments to the perineal muscles. When this has been done the whole segment including the rec- tum, the tumor and the lower sigmoid is readily drawn through the perineal wound. The chief disadvantage of this operation is that the patient is left with a permanent Colostomy. A number of surgeons are now attempting a new procedure which is designed to leave the rectal sphincter intact; the sigmoid colon is brought down through the sphincter, and thus a new and functioning anus is established. The substitution of this operation for the Miles operation will depend on the number of actual cures obtained. Nursing Care. The postoperative care of patients who have undergone a Miles operation not only includes that described for patients with extensive abdominal surgery (p. 233) and a colos- NURSING IN PROCTOLOGIC SURGERY 329 tomy (p. 312), but also the care of the perineal wound. These patients have usually been intubated for decompression of the intestinal tract prior to operation, and gentle suction is con- tinued afterward. Difficulty in urination is so regular a temporary complication of this operation that an indwelling bladder catheter is inserted immediately before operation. On return to the ward this is connected to straight drainage. The urinary out- put is regularly measured and recorded every six hours. Anti- biotic therapy is routine. Immediately following operation the nurse should observe the perineal dressings frequently in order to detect bleeding. Sterile gauze dressings and a cotton pad are placed over the wound; the dressings may be held in place with a modified T binder. It is essential that the wound be kept as clean as possible and that the bits of fibrin come off to promote quick healing. A urinal should be used by female patients to prevent soiling during uri- nation. If the dressing has become wet it must be changed imme- diately. Should the perineal wound become infected, as it occasionally does, the enzymes streptokinase and streptodornase are extremely useful in liquefying the discharge and promoting healing. As soon as the abdominal wound has healed, sitz baths can be given; these are very effective in cleaning up the perineal wound and in adding to the patient's comfort. Surgeons differ in their views on early ambulation following abdominoperineal resection of the rectum. The author prefers to permit his patients to remain in bed until the colostomy is ſunctioning and the Cantor tube out. This will usually be at least seventy-two hours after operation. At this time the indwelling bladder catheter may be removed and the patient allowed to try voiding. Should he be unsuccessful after a few hours, the catheter is reinserted. Instructions in colostomy care are given as outlined in the pre- ceding chapter. Included in the plan for total care are the details for care aſter discharge from the hospital. SUMMARY Rectal disease is extremely common, and ranges from minor annoyance to potentially lethal carcinoma. Diagnosis of these diseases is not difficult, requiring only that the patient take his complaint to a doctor who will examine the rectum. Bleeding from the rectum is a warning which should be heeded. Because 330 NURSING IN SURGERY OF THE ALIMENTARY TRACT i the rectum ordinarily contains pathogenic bacteria, rectal wounds are not expected to heal without infection; nevertheless, the re- sults of rectal surgery are remarkably satisfactory. VOCABULARY REVIEW impaction hemorrhoids incontinence fissure ischiorectal abscess sitz bath pruritus * fistula SUGGESTED READING 1. Agnew, James W.; Abdomino-perineal Resection. Am. J. Nursing, 51:225– 226 (April) 1951. 2. Carmel, A. Gerson: Proctologic Nursing. Am. J. Nursing, 48:626–629 (October) 1948. 3. Dericks, Virginia C., and Robeson, Kathryn: Problems of Colostomy Patients. Pub. Health Nursing, 41:16–27 (January) 1949. 4. No One Knows I Have a Colostomy: Am. J. Nursing, 51:703–704 (Decem ber) 1951. . Patterson, Mary G.: The Care of the Patient with Cancer. Pub. Health Nuns ing, 42:377–383 (July) 1950. 6. Streuben, Ethel M.: Nursing Care for the Patient with an Abdomino-perineal Resection. Am. J. Nursing, 51:226–228 (April) 1951. 5 Unif V. SURGERY OF THE URINARY TRACT CHAPTER 29 Nursing in Urologic Surgery Anatomy and Physiology. The urinary tract is Composed of the paired kidneys and ureters, the urinary bladder, and the urethra. Kidneys. The kidneys are located in the upper posterior part of the abdomen on each side of the vertebral column, behind the peritoneal cavity. They are well protected from external injury by fat, the lower ribs, and the thick lumbar muscles. Each kidney receives a large branch (renal artery) from the aorta and returns a large tributary (renal vein) to the vena cava, so that a consid- erable volume of blood constantly circulates through these organs. The product of the kidney, urine, is processed from the blood by the highly specialized epithelial cells of the glomeruli and tubules in the renal cortex; it then passes down the collect- ing tubules into the kidney pelvis, an epithelial-lined cavity in the hilum of the kidney. The renal pelvis funnels into the ureter, through which the urine is conducted into the bladder. Ureters. The ureters are about half the diameter of a lead 331 332 SURGERY OF THE URINARY TRACT pencil; they are lined with epithelium, and have a strong coat of smooth muscle fibers which undergo contraction waves for the propulsion of the urine, similar to the peristalsis of the intestinal tract. On each side the ureter courses downward from the kidney pelvis, passes behind the peritoneum, crosses over the iliac vessels at the pelvic brim, lies to either side of the sigmoid colon in the pelvis, and crosses the floor of the pelvis to reach the base of the urinary bladder. The terminal portions of the ureters pass ob- liquely through the muscle of the bladder wall; the openings (ureteral orifices) are at either end of the base of the trigone, a triangle of which the vesical orifice (beginning of the urethra) forms the apex. Urinary Bladder. The urinary bladder lies immediately be- neath the symphysis pubis outside the peritoneal cavity in the anterior and lowermost portion of the abdomen. It has an epi- thelial lining and a heavy coat of smooth muscle fibers. Col- lapsing completely when empty, the bladder in the adult has a normal capacity of 300 or 400 cc. Normal kidneys secrete urine continuously, although the rate of secretion depends upon numerous factors, and the urine is transmitted to the bladder by the ureters; this is an intermittent process, however, and urine enters the bladder from the ureteral orifices in tiny gushes or jets. The urine accumulates in the bladder, gradually distending it, and as the distention approaches the bladder capacity the desire for micturition becomes increas- ingly appreciated. Voiding results in relief and an empty bladder. Urethra. The bladder outlet (vesical orifice) opens into the urethra, and in the bladder wall in this region are the sphincter muscle and its nerves, which have the important function of Con- trolling the discharge of urine through the urethra, the act of voiding (micturition). The male urethra passes through the prostate (prostatic urethra), beneath the skin of the perineum (membranous urethra), and along the length of the penis (penile urethra), terminating at the external opening (external urinary meatus) at the tip of the penis. The female urethra is very short; it is generally believed that this fact accounts for the greater in- cidence of cystitis and pyelitis in females, as it is mechanically much easier for bacteria to gain entrance to the female bladder. METHODS OF EXAMINING THE URINARY TRACT As in every branch of medicine and surgery, the first and most important steps are the taking of a careful history of the patient's NURSING IN UROLOGIC SURGERY 333 illness and the performance of an exacting physical examination. Much additional confirmatory and even essential information, however, is gained from special examinations, including urinal- ysis, renal function tests, cystoscopy, and roentgen visualization. The preparation of the patient for these examinations, the per- formance of some of the tests, and the Collection of specimens are a part of surgical nursing. It must be emphasized that the results of these special examinations are reliable only when the examina- tion is conducted according to established standard conditions. This is particularly true of renal function tests. Examination of the Urine. Proper Collection and examination of the urine show the amount secreted during the period of Col- lection, the nature and concentration of the Constituent Chemi- cals, and the presence or absence of abnormal substances, cells, or bacteria. Preliminary examination is made of a specimen freshly voided into a clean container. The volume and specific gravity are measured and the appearance is noted. Small samples are then tested for reaction (acid or alkaline), for albumin, and for sugar. A portion is centrifuged and the sediment is examined microscopically to determine the nature of such crystals, casts, bacteria or cells as may be found. Normal urine does not contain albumin or sugar, and there should be no bacteria or cells except an occasional epithelial cell from the lining of the urinary tract. If the specimen cannot be examined as soon as voided it should be placed in a refrigerator; even so, the results of study will be less reliable, as cells sometimes break up and disappear. In the care of the urologic patient it is a routine procedure to measure and record on a twenty-four hour basis the volume of all urine, as the daily total output has much significance. Two-Glass Test. A convenient way of determining the origin of pus (leukocytes) in male urine is to have the patient divide a voiding into two glasses. The first specimen washes out the penile urethra, whereas the second specimen contains practically pure bladder urine. Pus in the first glass, therefore, indicates an in- flammation of the penile urethra only (anterior urethritis), while pus in both glasses indicates inflammation in the bladder (cystitis) or higher in the urinary tract. Urine Cultures. In infection of the urinary tract it is important to identify the causative bacteria; stained smears of the sediment of Centrifuged urine are helpful, but usually a culture is necessary for positive identification. An essential part of this test is to obtain urine without contamination from outside sources. In the 334 SURGERY OF THE URINARY TRACT male, unless the patient has urethritis, sufficiently uncontami- nated cultures may be obtained by cleaning the end of the penis (glans) with 70 per cent alcohol or tincture of Zephiran, follow- ing which the patient voids directly into a sterile culture tube. If it is necessary, however, to know which kidney may be harbor- ing bacteria, the specimen for culture must be taken directly from the kidney pelvis or ureter during cystoscopy. It is usual to obtain a specimen by catheter from females for Culture and microscopic examination. Phenolsulfonphthalein Test. This Commonly used test of renal function, usually called the “phthalein test,” is a convenient and accurate method of measuring renal function. Phenolsulfon- phthalein, a nontoxic dye, is injected intravenously; it is elim- inated rapidly from the circulating blood by the kidneys, appear- ing in the urine within two to five minutes after injection. If the kidneys are functioning normally, 60 to 80 per cent of the dye is excreted within two hours after injection. The routine procedure for the two-hour total phthalein excre- tion is as follows: The patient is given 400 cc. of water; he then empties his bladder as completely as possible, immediately after which he is given 1 CC. of phenolsulfonphthalein intravenously. The patient voids one hour and two hours after the injection, emptying his bladder each time. The two specimens are collected separately, properly labeled, and sent to the laboratory. Phthalein is colorless in acid solutions, bright red in alkaline. In the labora- tory the output of phthalein is measured by adding sodium hydroxide for alkalinization, diluting the specimen up to 1 liter by adding water, and Comparing a sample against samples of known Concentration in a Colorimeter. A variation of this test is Carried out during cystoscopy when one ureter is catheterized. In this modified phthalein (differential) test the appearance time can be noted, and the function of the two kidneys measured separately as the bladder urine comes from the ureter which is not catheterized. Cystoscopy. Although there are several varieties of cystoscope, the purpose of all is the same and that is to visualize the interior of the bladder. Because of the length and the narrow diameter of the male urethra, water cystoscopy is used in male patients. The instrument is in essence a large-bore metal catheter, carrying a telescope, an electric bulb for illumination of the bladder, and a tube to permit withdrawal or insertion of ſluid, and through which ureteral Catheters or small instruments are introduced NURSING IN UROLOGIC SURGERY 335 Eyepiece Dr. Ureteral orifice FIGURE 92. Water cystoscopy. Inset shows view of ureteral orifice as seen through cystoscope. and manipulated. Cystoscopy is carried out under rigid aseptic precautions, and some form of anesthesia is necessary. The Op- erator scrubs as for any surgical procedure. The penis is cleaned with aqueous solution of Zephiran. Anesthesia. Adequate anesthesia for cystoscopy is usually ob- tained by the instillation of xylocaine 1 per cent into the urethra and bladder, but in difficult cases sacral or spinal anesthesia may be necessary. For children or very nervous persons general anes- thesia is advisable. The patient is prepared beforehand as for a laparotomy. An enema is given in order to help eliminate as much intestinal gas as possible so that roentgen examinations will be more satisfactory. Shortly before cystoscopy the patient is given 400 cc. of water to ensure an adequate urinary output dur- ing the examination, particularly if a differential phthalein test is to be made. Morphine is usually given when the treatment is begun. Care of Instruments. Since the materials and the construction 336 SURGERY OF THE URINARY TRACT of a cystoscope do not withstand sterilization by heat, careful cleaning followed by chemical sterilization is necessary. A satis. factory method is to soak the instrument (taken apart) in a basin containing a solution of 1:1000 of Zephiran (aqueous). Ureteral catheters are sterilized in the same manner. Rubber kidney catheters are available which may be sterilized by boiling. After removal from the boiling water, they should be dropped into cold sterile water at once to stiffen them. They may then be placed in a sterile glass tube and labeled. Nursing Care Following Cystoscopy. Introduction of the Cysto- scope causes irritation of the smooth muscle fibers which is mani- fested by painful contractions, and following the examination there is discomfort as soon as the anesthesia wears off. Many sur- geons order opiates; some order scopolamine or atropine, depend- ing on the amount of pain the patient seems to have. Most pa- tients feel well aſter twenty-four hours of rest in bed, forced fluids, and application of a hot water bottle to the lower ab- domen. Sitz baths also are helpful in alleviating pain. The total intake of fluids for the twenty-four hours after a cystoscopy should be 5 liters. Roentgen Visualization of the Urinary Tract. Calculi (stones) of the urinary tract may be seen in plain x-ray films of the abdo- men. Two additional methods of visualization are Commonly used: intravenous pyelography and retrograde pyelography. Intravenous Pyelography. This is accomplished by the in- travenous injection of an iodine-containing Compound which is eliminated from the blood by the kidney in sufficient concentra- tion to render the urine temporarily more radiopaque than the adjacent soft tissues; a film made at this time will outline the renal pelves, ureters, and bladder, provided renal function is not too much impaired by disease. The solution commonly used is Urokon. The patient is prepared by administering an enema and withholding food and fluids for at least eight hours before the examination, for a high Concentration is desired. A plain roent- gen film is taken first; then the dye is injected intravenously. X-ray films are made five, fifteen, and thirty minutes after the injection. As might be expected, intravenous pyelography is most satisfactory when there is no disease of the urinary tract. Retrograde Pyelography. The most accurate and satisfactory roentgen visualization of the tract is accomplished by retrograde pyelography. The chief disadvantage of this method is that it requires cystoscopy and ureteral catheterization. With the ure. NURSING IN UROLOGIC SURGERY 337 teral catheter inserted up to the kidney pelvis, 3 to 8 cc. of radi- opaque solution is injected into the pelvis through the catheter and a roentgenogram immediately made without moving the patient. The catheter is then withdrawn part way and a second film taken, showing the ureter. Some urologists prefer not to catheterize both ureters at the same sitting because there is occasionally a temporary renal shut- down following ureteral catheterization, which is not serious if only one kidney is involved. This means that two cystoscopies are necessary for retrograde pyelograms of both kidneys, which is an added drawback. Air Cysfoscopy. This technic, in which a straight open-bore tube is used, is possible in women because of the shortness of the urethra and because of the ease with which it can be dilated. The advantages of this method over water cystoscopy include greater simplicity of equipment, direct view of the bladder, and the ability to use ureteral bougies and catheters with a larger bore. A real disadvantage, however, is that the examiner cannot visu- alize the entire bladder, whereas the arrangement of lenses of the water Cystoscope permits visualization of virtually all of it. Technic. The patient is prepared first as for water cystoscopy. She is draped for pelvic examination (Chap. 48); the bladder is Catheterized and xylocaine is instilled into the urethra. Pelvic examination is then made, following which the patient is shifted to the knee-chest position and made as comfortable as possible. The perineum and external genitalia are cleaned with aqueous Zephiran. The urethra is gently dilated with a series of smooth metal (Hegar) dilators up to 11 F. The Kelly cystoscope is passed into the bladder and its obturator removed; as this is done there is always a rush of air into the bladder which is opened by the pull of gravity upon the dependent abdomen. The operator wears a head mirror which reflects a narrow beam of light through the cystoscope into the bladder. All details of technic are the same as in water cystoscopy with the exception of the use of wax bulbs. Because of the larger bore of the air cystoscope, it is possible to apply a wax bulb to the tip of the ureteral catheter. The wax bulb is made just before use by melting a bit of sterile beeswax, dropping it onto the tip of the Catheter, and molding this drop until it has the desired thickness. The wax bulb can be made larger or smaller as needed, and it furnishes an accurate method of estimating the diameter of the ureteral lumen, and of judging the results of the dilatation of 338 SURGERY OF THE URINARY TRACT º < C a the ter. FIGURE 93. Air cystoscopy. ureteral strictures. An additional advantage of the wax bulb is that the wax will be scratched if it passes over a calculus; thus a scratch on the wax bulb seen after withdrawal of the Catheter indicates the presence of a calculus. Indeed, an occasional small stone becomes adherent to the wax and in this way is delivered from the ureter. PREPARATION OF INSTRUMENTs. The Kelly cystoscope is all metal and is sterilized by boiling. The ureteral catheters used in air cystoscopy are stiffened by wire stylets. The catheters and the stylets are sterilized separately either by soaking in 1:1000 oxycyanide of mercury or by boiling for ten minutes, according to their composition. Then a nurse, scrubbed just as though ready for an operation and in sterile gown and gloves, inserts the stylets into the catheters. Small sterile rubber shields are placed on the ends of the catheters and then they are put into long sterile glass tubes which are plugged with sterile cotton and labeled with the date of sterilization and the size of the catheter. There are two types of ureteral catheters. The catheter which is used for collecting specimens and lavaging the kidneys is the plain renal catheter. The other type is permeated with bismuth NURSING IN UROLOGIC SURGERY 339 so that when an x-ray film is made it will be seen in the x-ray film. This type may also be employed for the same purposes for which the plain renal catheter is used. NURSING CARE. Following air cystoscopy the nursing care is the same as after water cystoscopy (p. 336). CONGENITAL DEFORMITIES Exstrophy. In this unusual and serious anomaly of the new- born the urinary bladder lies out on the lower abdominal wall and is open. The infant is obviously incontinent; the ureteral orifices are in plain sight. Infection of the tract soon occurs. Plas- tic surgery offers hope of cure by closing the bladder, but unfor- tunately these little patients often have other and less remediable deformities as well. Reduplications. Double ureter, double renal pelvis, and even double kidneys occasionally occur; more rarely, these conditions are bilateral. Function is usually unimpaired and no treatment is necessary. Other Renal Anomalies. Occasionally there is total absence of one kidney; it is always essential, therefore, before contemplating the removal of a kidney, to make sure that there is a normally functioning kidney on the opposite side. Misplaced (ectopic) kidneys are not uncommon; they are usually asymptomatic, but unless the mass can be positively identified in some other way, the discovery of an asymptomatic mass in the midabdomen or pelvis calls for roentgen visualization of the upper urinary tract. Another uncommon renal anomaly is a fusion of the two kid- neys across the posterior abdomen, forming the so-called horse- shoe kidney. Multiple cysts of the kidney (polycystic kidney) occur and may replace much of the renal cortex, resulting in loss of kidney function. Pain, increasing size, or inſection may necessitate the removal of such a kidney. DISEASES OF THE BLADDER Cystitis. Inflammation of the lining of the bladder results from the introduction of pathogenic bacteria from without by way of the urethra, or by descent of bacteria in the urine from an in- ſected kidney. Symptoms. The patient complains of pain in the lower abdo- men, of increased frequency and urgency of urination, and of burning during urination. There is often ſever, and examination of the urine shows pus, that is, large numbers of white blood cells. 340 SURGERY OF THE URINARY TRACT Treatment. Unless there is an obstruction which prevents the complete emptying of the bladder, or unless bacteria continue to come into the bladder from the kidneys, cystitis responds readily to treatment which includes the forcing of fluids and appro- priate antibiotic and drug therapy. Cultures are always taken so that therapy may be specifically directed at the causative bac- teria. If the cystitis does not clear up promptly following the use of these simple therapeutic measures, the patient should have a cystoscopic examination as the inflammation may be due to the presence of a stone (calculus) or an ulcer. Refertion. Retention of urine in the bladder may be acute or chronic. The causes in general are three: mechanical obstruc tions, such as urethral stricture or prostatic enlargement in the male; acute inflammatory disease adjacent to the lower tract, such as perirectal abscess; and neurologic disease or injury which disables the control mechanism of the nervous system. Symptoms. The patient complains first of difficulty in initiating micturition, and later is unable to empty the bladder completely, so that there is constantly some residual urine, a Condition favor ing the persistence of infection. The bladder muscle, working against obstruction, becomes hypertrophied, but occasionally a weak spot develops which leads to the formation of a di- verticulum. In acute retention there is complete inability to void, but when the bladder becomes overdistended (the capacity may reach 1500 cc. or more) there is often continual or intermit- tent seepage through the urethra; this is known as paradoxical 177 CO77 tº 77 e?? Ce. Treatment. The treatment of retention depends upon the cause, but obviously one important feature is to establish urinary drainage promptly. This may be accomplished by the insertion of an indwelling catheter, by repeated catheterization, or, if pas- sage of a catheter is not possible, by making an operative open- ing into the bladder through the abdominal wall (cystostomy). The emptying of an overdistended bladder should be accom plished gradually, as too sudden release of the pressure may cause renal hemorrhages and failure. Complication. If the retention is due to injury or disease ol the central nervous system it is likely that the paralysis of the bladder control mechanism will be of long duration or perma- nent. The long continued use of an indwelling catheter will certainly result in urinary tract infection, an often ſatal Com- plication in such cases. Fortunately in these patients an auto- NURSING IN UROLOGIC SURGERY 341 FIGURE 94. Apparatus for intermittent bladder irrigation and drainge. Irrigat- ing fluid drips slowly into the bladder through the T tube until the pressure inside the bladder is sufficient to raise fluid level in side arm of T tube up to A. When this occurs the fluid running over at A initiates a siphon into the drainage bottle which produces enough suction to empty the bladder. This cycle is then repeated, and its duration depends upon the rate of inflow of the irrigating fluid. matic bladder may develop, so called because it empties itself in- voluntarily when full. When infection does occur in a neurologic bladder the most useful method of handling the problem is by the use of the intermittent bladder irrigator apparatus, Com- bined with chemotherapy. In continence. Accidental trauma may damage the bladder Sphincter or control mechanism so that there is continual leakage 342 SURGERY OF THE URINARY TRACT of urine from the urethra. In males this incontinence may be controlled by a specially designed clamp worn on the penis. In- continence in females usually is a late Complication of child- bearing, and is apt to be of the stress variety, occurring chiefly when coughing, laughing or straining. This can be treated by an operation in which the sphincter is tightened. Neoplasms. Carcinoma not infrequently arises from the epi- thelium which lines the bladder. The appearance of blood in the voided urine is the symptom which usually causes the patient to seek aid. Unfortunately, bleeding from a tumor does not occur until the tumor is large enough to become ulcerated. A smaller tumor may be discovered earlier only if it is located near the ureteral orifice or vesical orifice, where it can cause the symptoms of obstruction. Diagnosis is made by Cystoscopic examination and biopsy. Fulguration or radiation of bladder cancers has not proved very satisfactory. Total removal of the bladder (cystectomy) offers more hope of a permanent cure. Cystectomy Surgical removal of the bladder necessitates the transplanta- tion of the lower ends of the ureters in order to provide for the excretion of urine. Ureteral transplantation is a formidable pro- cedure, and the greatest success has followed a method by which the ureters are implanted successively in stages into the sigmoid colon preliminary to cystectomy. This means that the urine is excreted through the rectum. As might be expected, there is some diarrhea at first, but it is amazing how well the patient with a successful transplantation gets along. The ureter must be im- planted in the bowel in such a way that no leakage occurs, that the chance for bacteria to enter the ureter from the colon is mini- mal, and that there is no constriction of the ureter which might cause obstruction to the outflow of urine with consequent dilata- tion of the ureter (hydro-ureter) and kidney (hydronephrosis). At the first operation one ureter is transplanted; as soon as heal- ing has occurred and satisfactory function is ascertained, the second operation, which includes transplantation of the remain- ing ureter and total removal of the bladder, is carried out. Complications. In addition to all the Ordinary Complications of any laparotomy, there are the possibilities of peritonitis from leakage of the wound in the Colon, urinary leakage into the peritoneum, and infection with or without obstruction of the upper urinary tract. Probably a certain amount of infection of NURSING IN UROLOGIC SURGERY 343 the upper tract always occurs; but since the advent of chemo- therapy and antibiotics this complication is not so serious as formerly provided there is no obstruction to urinary outflow into the bowel. Nursing Care. Preparation for cystectomy includes establishing good nutrition, adequate hydration and antibiotic therapy. Can- cer of the bladder is treated the same in either sex, but occurs about four times more often in men. The thought that the bladder must be removed and that the urinary excretion will be transferred to the intestinal tract is certainly not a happy one for the patient. The reassurance and kindness which the nurse offers are very helpful to the patient and are necessary to give him some security. Immediately before operation a Levine tube is usually placed in the stomach. The general preoperative and postoperative care is the same as that for laparotomy. In addition, the immediate postoperative care is aimed to facilitate the excretion of urine and maintain the electrolyte balance of the patient. A large Colon tube is usually kept in the rectum to drain the urine and feces until healing and renal function seem satisfactory; this is usually five to seven days. Irrigating the rectal tube with normal saline to insure patency by removing any fecal material is neces- sary. Following the removal of the tube, the nurse should learn from the surgeon the frequency he advises the patient to empty his bowel. It has been found when urine remains in the bowel, sodium chloride in the urine is partially reabsorbed by the bowel. To prevent this the bowel must be emptied frequently, usually every two to four hours. When excretion takes place this often it may lower the potassium content of the blood. To combat or prevent these disturbances the patient may be given a low chloride diet, supplemented with potassium salts. When the electrolyte balance becomes disturbed the patient may exhibit Some degree of acidosis characterized by nausea, vomiting, fa- tigue, weakness and loss of weight. Good nutrition is emphasized; a low residue, high caloric diet is frequently ordered as soon as the patient can take food. When sodium is limited, the proteins must obviously be decreased in the diet. While the patient is in the hospital blood studies are done frequently and the patient may be expected to receive whole blood and other fluids to maintain a normal blood level. When the patient has a colostomy or when the urine is ex- Creted through cutaneous openings in the abdomen, as after pel- 344 SURGERY OF THE URINARY TRACT vic exenteration, some type of bag must be worn to allow for the collection of urine. The bag or cup used for the cutaneous opening or colostomy may be the type cemented to the skin. The patient must be taught how to apply and remove the bag and how to clean the skin area. Skin cement is removed with benzine or ether. The skin is then thoroughly washed with mild soap and water, and dried well before the cement is reapplied. The surgeon and nurse should work out a complete plan of care for such a patient so that day by day instructions may be given in an assured and unhesitating manner. The onset of electrolyte imbalance may not occur until months aſter surgery. In preparing the patient to go home, it is important that the nurse emphasize follow-up care to permit a periodic checkup to evaluate his status so that he may be aided according to his need. DISEASES OF THE KIDNEY AND URETER Renal Trauma. The kidney is well protected from external violence, but penetrating wounds or severe blows upon the abdo- men or crushing wounds sometimes cause laceration of the renal cortex. Severe pain and tenderness over the kidney are accom. panied by gross blood in the urine (hematuria). Ordinarily the bleeding stops and the kidney heals with remarkably little loss of function. Occasionally, however, the damage is so great that the bleeding is dangerous and an immediate nephrectomy is neces sary to save life. Pyelitis. The commonest cause of inflammation of the lining of the kidney pelvis is infection with the colon bacillus or other pathogenic bacteria found in the large bowel. The explanation of this is obvious in patients who have had ureteral transplanta- tion, but there has been no satisfactory explanation of those infec. tions which often occur in patients who have had no operation. Pyelitis is not so common in men as in women. Whether the in- ſection is an ascending one to the kidney by way of the urethra, bladder, and ureter, or whether the infection is blood-borne is a matter of controversy; very likely it occurs in both ways. Symptoms and Diagnosis. The symptoms of pyelitis are aching pain in the flank and lumbar region, increased frequency and burning urination, and, occasionally, chills. The patient has fever and leukocytosis and feels badly, and examination of the urine shows large numbers of pus cells (leukocytes). Urine culture is done to identify the causative bacteria. It is important NURSING IN UROLOGIC SURGERY 345 to cure pyelitis because continued infection eventually leads to infection and destruction of the renal substance, which, in turn, finally causes renal failure. Treatment. Many patients with pyelitis respond rapidly to therapy which includes rest in bed, adequate fluids, and chemo- therapy. Other patients, in whom the offending bacteria are not susceptible to such chemotherapeutic and antibiotic agents as are now known, tend to develop a chronic infection which is very intractable. Of course, in any patient who has an associated ob- struction of the urinary tract the infection will not respond well to ordinary therapy until the obstruction is treated and re- lieved. Renal and Perirenal Abscesses. As the result of a blood-borne infection, usually staphylococcal or streptococcal, a large abscess forms in the kidney substance or in the fat about the kidney. Symptoms and Diagnosis. The symptoms are pain in the flank or back and the usual systemic symptoms of an acute infection. Often the diagnosis is difficult to establish as there may be at first no symptoms or signs of involvement of the urinary tract. Later there is tenderness in the region of the kidney, and pus cells appear in the urine. Pyelograms show distortion of the renal pelvis or displacement of the kidney. Renal function becomes impaired only if there is considerable destruction of the kidney COrtex. Treatment. Treatment consists in incision and drainage of the abscess together with antibiotic therapy. The prognosis is good unless the patient has abscesses elsewhere in the body, as often happens in blood-borne infections of this sort. Tuberculosis of the Kidney and Urinary Tracf. Tubercle bacilli enter the kidney substance from the blood stream; the primary site of the tuberculosis is always in the lungs. As the disease progresses, sooner or later a tubercle ruptures into the collecting tubules or renal pelvis, thus distributing the tubercle bacilli into the ureter and bladder, in which the typical lesions of the tuber- culosis then develop. Symptoms. Renal tuberculosis is an insidious disease, and is likely to have progressed far before causing symptoms. The first complaints are usually loss of weight, persistent unexplained ſever, or the appearance of blood and pus cells in the urine. Diagnosis. Diagnosis is established by the characteristic ap- pearance of the pyelogram, which shows irregular ulceration of the border of the calices of the pelvis, and by the identification 346 SURGERY OF THE URINARY TRACT of tubercle bacilli in the urine, which is done by examining stained smears and by making special cultures. Treatment. Careful examination must be made of the urine and function of each kidney, for if there is bilateral involvement the patient cannot be cured by surgery. If, however, only one kid- ney is infected and no tubercles are seen in the bladder, the surgical removal of the tubercular kidney is curative in the ma- jority of cases. These patients need, in addition to nephrectomy, the usual supportive and hygienic measures used routinely for all patients who have tuberculosis in any of its numerous manifesta- tions. Antibiotic and drug therapy is used. Urinary Tracf Calculi. Stones form in the kidneys, ureters and bladder, and vary in size from pinhead to large stag-horn calculi which fill the entire renal pelvis. The formation of stones cannot always be satisfactorily explained, but they are composed of the Crystals of the various chemicals found in urine, and almost al- ways contain calcium, carbonates, and phosphates, as well as other Crystalloids. One known cause of the formation of stone is the excessive excretion of calcium which occurs in hyperpara- thyroidism; the finding of repeated urinary calculi in a patient should lead to examination for a parathyroid adenoma. Stones in the kidney may produce no symptoms, but if urinary tract in- fection occurs, the stone may be discovered in the search to find a reason for the persistence of infection. Often, however, stones cause obstruction, and one of the most severe varieties of pain, i.e., renal and ureteral Colic, is caused by the passage or attempted passage of small calculi from the renal pelvis through the ureter to the bladder. Symptoms. The characteristic clinical picture of nephrolithiasis or ureterolithiasis is an attack of excruciating, Cramplike pain in the flank, lower abdomen, and groin. Accompanying this are urinary frequency and the appearance of gross blood in the urine, caused by the abrasive action of the stone as it is passed. Diagnosis. Following subsidence of the acute colic, the urologist attempts to locate the stone. All urine is collected and strained so that a stone may not be passed per urethram undetected. Plain roentgenograms and pyelograms are usually necessary. Treatment. Large doses of morphine are necessary to relieve the pain. If the stone is lodged in the ureter, it may sometimes be dislodged and passed following the passage of a ureteral cathe- ter or bougie. A stone in the renal pelvis or one firmly fixed in the ureter must be removed surgically (nephrolithotomy or uretero- NURSING IN UROLOGIC SURGERY 347 FIGURE 95. Retrograde pyelograms. A, Normal; B, bilateral hydronephrosis. lithotomy); otherwise there may be permanent damage to the kidney and loss of renal function consequent to the obstruction. Hydronephrosis. A gradual or partial obstruction to the out- flow of urine from the kidney produces progressive dilatation of the renal pelvis, which may become very large, with consequent destruction of the renal cortex. In an advanced hydronephrosis the kidney is little more than a hollow shell containing a large pelvis. Obviously the most important result of this condition is the progressive loss of renal function. If the obstruction is re- lieved early, the kidney shows a considerable ability to regain normal function and may do so completely; but if the hydrome- phrosis is large and of long duration the function is permanently lost. A sudden complete obstruction, on the other hand, usually results in renal shutdown followed by rapid and permanent atrophy of the kidney. There are many causes of hydronephrosis, including congenital valves or kinks in the ureter, aberrant blood vesels which obstruct the renal pelvis at its junction with the ureter, calculi, swelling due to infection, obstruction to the outflow of urine from the bladder, and neoplasms. Symptoms. Hydronephrosis may be asymptomatic, but at times there is dull pain in the flank, and if the hydronephrosis is large, 348 SURGERY OF THE URINARY TRACT a mass is felt in the kidney region. If infection is present the systemic symptoms and signs are apt to be severe. Diagnosis. Diagnosis is made on the basis of pyelography, which readily demonstrates the enlarged renal pelvis. Treatment. Treatment depends upon the cause, the amount of renal function remaining, and the severity of the infection if present. An attempt is made to clear up the infection by ureteral catheterization and drainage together with chemotherapy, but if ureteral drainage is not feasible a direct operative opening is made into the kidney (nephrostomy) for drainage. If the ob- struction is amenable to surgery, the necessary procedures are done. In cases in which there is infection plus permanent severe loss of renal function, however, removal of the kidney is the procedure of choice. Neoplastic Disease. Renal tumors are of Common occurrence and most of them are malignant. Unfortunately, symptoms ap- pear late, often too late for cure, as the first symptom may be the pain in bones due to metastases. Bloody urine (hematuria) with- out pain, loss of weight, and the discovery of a mass in the flank are the usual signs of a renal tumor. The diagnosis is established by pyelography, which shows a characteristic deformity of the renal pelvis. If the tumor has not spread beyond the kidney cap- sule, cure is effected by nephrectomy. Kidney tumors which occur in children differ from those seen in adults. Arising from tissues of nervous origin, they are quite radiosensitive. Nephrectomy combined with deep x-ray therapy results in Some cures. Operations on the Kidney Removal of a stone through an incision in the kidney cortex is called nephrolithotomy; if the incision is made in the kidney pelvis for extraction of a stone it is called pyelolithotomy. A sim- ple opening into which a tube is inserted for drainage is called nephrostomy. Nephrectomy and other procedures are not undertaken until there is Complete information as to the condition and function of the opposite kidney as well as of the diseased one. The patient is prepared as for any abdominal operation. Spinal anesthesia is Somewhat more Satisfactory than inhalation anesthesia, as Com- plete muscular relaxation is important for proper exposure of the kidney. Approach to the kidney is made through an incision parallel with the lowermost rib in the flank. The posterior NURSING IN UROLOGIC SURGERY 349 32 ºfflº 2 * * * * Z/-. ... - > º 52. ** = ~~ FIGURE 96. Nephrolithotomy. The incision in the kidney will be closed by SUltureS. peritoneum is retracted and the peritoneal cavity is not entered. Removal of the kidney is a difficult operation because of the shortness of the large renal vessels which must be divided and ligated. Serious loss of blood is not uncommon, and transfusion is a routine matter. The wound is sutured but drains are always employed. Except in the case of nephrectomy, there are copious amounts of drainage, largely urine, so that the dressings need fre- quent changing. The postoperative complications are the same as in a patient who has had a laparotomy. Nursing Care. Preparation to receive the patient is like that after a laparotomy. After plastic repairs and nephrectomy the pa- tient is turned from his back to the side of operation for the first forty-eight hours, but after this period turning from side to side is encouraged. All other patients are turned from side to side So that pulmonary complications and distention may be pre- vented. When a catheter has been inserted into the kidney it is usually connected to sterile rubber tubing which drains into a bottle at the bedside. Unless the drainage from this catheter lead- ing from the kidney is more than 5 cc. per hour, the surgeon must be notified at once. It is important that all voided specimens as well as the drainage be accurately measured and recorded. 350 SURGERY OF THE URINARY TRACT Fluids are forced throughout the convalescence; the daily amount varies with the condition of the patient but it is usually no less than 3 liters and no more than 5 liters. Diet is withheld for the first day; a liquid diet may be given the second day, a soft diet the third day, and a regular diet on the fifth or sixth day. The dressings are changed whenever necessary; the wound and surrounding skin should be thoroughly cleaned each time that the dressings are changed. The length of time that the patient remains in bed varies with the condition of the patient; at times he is gotten up as early as the fifth day, but the twelfth day seems to be more common. Lifting of heavy weights should be avoided for three months following operation. SUMMARY Although the urinary tract is but a small part of the human body, the diagnosis and treatment of urologic inſections, ob- structions, and neoplasms require special technics and equip- ment. The only significant difference between the male and fe- male urinary tract is the length of the urethra. The continuous excretion of urine is essential to life, and the maintenance of this function is the aim of urology. VOCABULARY REVIEW wºreter phenolsulfon- cystectomy urethra phthalein hydronephrosis micturition pyelography nephrolithotomy cystoscope exstrophy SUGGESTED READING 1. Christopher, Frederick: Textbook of Surgery. 5th Ed. Philadelphia, W. B. Saunders Co., 1949, pp. 1225–1287. 2. Davis, D. M., and Strong, G. M.: Urological Nursing. 5th Ed. Philadelphia, W. B. Saunders Co., 1953. 3. Fleming, Elizabeth C.: Kidney Stone. Am. J. Nursing, 49:568-570 (Septem- ber) 1949. 4. Korenberg, Morton: The Electrolyte Disturbance in Ureterocolostomy. J. Urol., 66:686–687 (November) 1951. 5. McLester, James S.: Nutrition and Diet in Health and Disease. Phila- delphia, W. B. Saunders Co., 1949, pp. 452–484. 6. Nººn. Kathleen: Urologic Nursing. Am. J. Nursing, 50:167–170 (March) 1950. 7. Rusche Carl: Preparation, Operative Technique and Postoperative Man- ºnent of Uretero intestinal Anastomosis. J. Urol., 65.550–552 (April) 1951. NURSING IN UROLOGIC SURGERY 35 I 10. 11. . Daut, Richard V.: Urologic Conditions in Women. Am. J. Nursing, 50:479– 482 (August) 1950. . Everett, Houston S.: Urology in the Female. Am. J. Surgery, 52:521–659 (June) 1941. Wharton, Lawrence R.: Gynecology Including Female Urology. Philadel- phia, W. B. Saunders Co., 1943, pp. 769–962. Lowsley, Oswald Swinney, and Thomas Joseph Kirwin: Clinical Urology. 2nd Ed. Baltimore, Williams and Wilkins Co., 1944, pp. 1102–1205. Unit VI. SURGERY OF THE INTEGUMENTARY SYSTEM CHAPTER 30 Nursing in Plastic Surgery Plastic surgery is the operative correction of congenital or acquired deformities for the purpose of restoring function and improving appearance. The scope of the subject is broad: in- deed all surgery is plastic surgery, in that the careful surgeon always tries to avoid unsightly scars and interference with proper function. The art of plastic surgery is ancient. As early as 800 B.C. Hindu physicians were familiar with skin shifting operations and had developed a technic for reconstructing the nose with a flap shaped from the forehead and hinged downward. Essentially the same operation is often utilized today. Plastic procedures were em- ployed and described in the first century A.D. by Celsus, a Roman, and the writings of Galen, who lived in the second century, contain references to plastic operations. In the fifteenth century a Sicilian named Branca repaired and reconstructed noses by 353 354 SURGERY OF THE INTEGUMENTARY SYSTEM transferring flaps of skin from the arm. Despite this early prog- ress, interest in the subject lagged until the middle of the nine- teenth century, since which time the development and perfec- tion of anesthesia, asepsis, and operating methods have provided surgeons with the means for greater accomplishments. The mu- tilations resulting from the two world wars gave further im- petus. * GENERAL PRINCIPLES Of utmost importance in plastic surgery are gentleness and care in the handling of tissues. Avoidance of bruising, the most rigid aseptic technic, careful and delicate hemostasis, and scrupu- lous regard for detail are necessary for satisfactory results, for contused and infected tissues heal with unsightly scars. Operators must use the finest instruments, the slenderest needles, and the most delicate suture materials. Surface stitches are removed as soon as safety permits to avoid additional skin markings. Dead spaces must be eliminated, and tension on tissues must be avoided. The placing of incisions along natural skin lines makes the scars less noticeable. Selection of Grafts. In the transplantation of tissues and in the transfer of grafts the surgeon utilizes his knowledge of different methods to select the one most suitable for the purpose. Trans- planted tissues should resemble in texture and color the surfaces to which they are to be transferred. Good results can be accom- plished by careful selection as the body provides a variety of skin colors, thicknesses, and textures. For example, the skin of the neck and that which lies behind the ear is thin, soft and pliable. As a rule it presents gradation in pigmentation, and it can readily be transferred to the face. Skin from the inner surface of the upper arm or thigh is also delicate but paler. Skin from the back and shoulders is thick and heavy and in general less useful for full-thickness grafting although it provides adequate material for the split-thickness graſt. Technics have been developed whereby grafted skin can be tattooed and impregnated with harmless pig- ment to blend closely with the skin of the face or lip or the hair- bearing cheek. Alterations of the nose for cosmetic reasons de- mand careful study and frequently the Construction of a cast of the face in plaster before surgery is undertaken. Grafts which are transferred from distant parts of the body are not elevated until thorough study has determined the safest and simplest method and the most favorable donor site. In such instances the preserva- NURSING IN PLASTIC SURGERY 355 tion of the blood supply is of great importance and at times as: sures the success of the procedure. Anesthesia. Operative procedures about the face present prob- lems in anesthesia and frequently necessitate intratracheal in- tubation and the administration of “anesthesia at a distance.” Local or regional block anesthesia with xylocaine is especially useful. Preoperative and Posfogerative Care. Prophylaxis against po- tential infection by means of antibiotic therapy, the Correction of anemia and hypoproteinemia before operation, and considera- tion of possible avitaminoses are all invaluable aids in securing satisfactory wound healing. Conscientious postoperative care is often the deciding factor in a successful operation. Closure of Defects Defects of varying sizes in the skin and underlying tissues re- sulting from the excision of tumors or from accidental wounds can frequently be repaired and made inconspicuous by the local readjustment of tissues. The inherent property of elasticity in the skin permits it to be stretched and extended after proper and sufficient undermining. Triangular defects may be closed in a Y; oval defects are convertible into a T; rectangular ones may be made into an ellipse and sutured in a straight line, or the borders of the rectangle may be extended and undermined and the flaps thus formed sutured in the fashion of an H. Additional incisions or excisions may be made adjacent to a defect to permit the rota- tion of skin to cover the denuded area. Repcir of Scars All incisions and wounds, no matter how acquired, leave scars upon healing. The cosmetic result is dependent upon a number of factors, such as tension, infection, loss of substance, careful handling, and the like. Unsightly scars can frequently be excised and replaced by more presentable ones. Depressed scars resulting from the loss of deep structures are corrected by thorough excision and repair which unites these deep tissues to form a proper support for the skin. Such scars commonly occur in the healing of carbuncles and deep infections which have re- Sulted in extensive destruction of tissue. Repair of Keloids Certain persons, especially Negroes, have a tendency to produce thick, weltlike scars (keloids); masses of connective tissue are 356 SURGERY OF THE INTEGUMENTARY SYSTEM Scar contracture N 90) \ ) v_2% FIGURE 97. Z-plasty for relaxation of contracture. Following the Z incision (A), flaps X and Y are elevated (B), and transposed (C). found in keloids, as though the proliferative process in wound healing failed to stop at the proper time. The removal of such heaped-up and deforming scars can often be satisfactorily effected surgically, and the prevention of further keloid growth can be accomplished by careful x-ray therapy. Repair of Contractures One of the characteristics of scar tissue is its tendency to con- tract. Scars which cross joints, therefore, even though they may heal by first intention, are apt to produce contractures which limit or prevent motion. Relaxation and free motion can often NURSING IN PLASTIC SURGERY 357 be restored by the simple Z-plasty. In this procedure two tri- angular flaps of equal size are elevated adjacent to the line of contracture. The excised contracted scar forms the middle bar of the Z. The flaps are then rotated so that their apices cross the line of contracture, increasing its length by about 50 per cent. This simple procedure finds application in the relief of con- tractures of the fingers and thumb, the wrist and elbow, and even large surfaces such as the neck, the axilla, the knee, and the thigh. Wide scars, however, must be treated by more elaborate methods. Pilonidal Cyst and Sinus In the skin of the posterior midline of the body, over the lower sacrum, are occasionally found small epithelial-lined cysts, which may communicate by means of small pores with the exterior. The lining of these cysts or sinuses is usually hair-bearing, which ex- plains the name pilonidal (nest of hair). Pilonidal cyst and sinus are congenital defects, more common in males than in females, and do not cause symptoms unless infection occurs. The symp- toms and signs are similar to those of any acute localized infec- tion, and the immediate treatment consists in the application of heat and later, if necessary, surgical drainage. If the patient has repeated attacks of inflammation it is necessary to excise the cyst or sinus in order to accomplish a permanent cure. SKIN GRAFTING The procedure of transferring a portion of skin from one area to another area in the same individual is called an autograft, whereas the transfer of a graft from one individual to another of the same species is called a homograft. Autografts are generally successful, and the graft in its new site becomes a permanent fea- ture. Homografts, on the other hand, as a rule are not successful, except in certain special instances. Although it would be de- sirable to be able to use skin from one individual for another, as in severe burns, the results do not justify such a procedure. Small Deep Grafts. The simplest type of skin graft is the free graft. Segments of skin are cut from one portion of the body (donor area) and transferred to the site where needed (recipient area). This principle was used by Reverdin, who found that small superficial pieces of epithelium would survive and grow when transplanted to granulating surfaces. A ſurther and more useful application of this principle was developed by Davis in the small 358 SURGERY OF THE INTEGUMENTARY SYSTEM S. = \--~~A → : FIGURE 98. Small deep grafts. Depth of graft and method of cutting are shown at a and b. NURSING IN PLASTIC SURGERY 359 deep graft which, although only 5 to 7 millimeters in diameter, contains in its central portion the full thickness of the skin and provides a thicker and healthier type of covering. Hundreds of these grafts can be cut from the thigh or any other desired site and can be seeded on large granulating areas to form islands of epithelium which grow out in all directions to coalesce and cover the defect. This type of graft has been especially useful to cover extensively burned areas which have become infected. They also provide durable covering in chronic ulcers of the leg. Useful as they are, there is, however, one major objection, for the resulting epithelialization is spotty and presents a less attractive Cosmetic result than whole-thickness or split-thickness grafts which have an unbroken surface. Small deep grafts are easily cut under local anesthesia, even in small children, and their care is relatively simple. Both donor and recipient areas are usually dressed with a layer of petrolatum or xeroform gauze under a little pressure. The donor area is not disturbed for ten days, at which time it is usually found to be healed. The grafted area is dressed in four or five days. Occasionally, when the surface is heavily infected, the dry dressing may be replaced by saline compresses which are changed frequently. The addition of penicillin to the salt solu- tion is often beneficial. Free Full-thickness Graft. Small defects can be covered by full-thickness skin excised from the neck or the inner surface of the arm or thigh and transferred to the area to be repaired as free grafts. The donor area is usually closed immediately. The size of the graft is limited, for these graſts depend for their viabil- ity upon the rapid establishment of nutrition from the new base, and their early life is precarious. Small areas about the face can be covered satisfactorily by this method. The cosmetic effect in these relatively minor procedures is usually pleasing, but the Con- ditions for success are exacting. Viability in free full-thickness grafts is usually evident after four or five days. There may be Some superficial and harmless desguamation. Split-thickness Graft. This graſt has been growing in popular- ity and usefulness in recent years. It is cut either by free hand or with a mechanical device, and consists in a sheet of epithelium which is only a portion of the full thickness of the skin. Regenera- tion and healing take place rapidly on the donor site with mini- mal scarring. The first of these grafts was described by Ollier and Thiersch. They were usually cut free-hand with a long-bladed knife from 360 SURGERY OF THE INTEGUMENTARY SYSTEM // t % Wºº- º N jº § NSW Nº S& § 3 % tºº, § 3 2 2//S E: § \\ Williuſ/ull | % § 4 II. ** §ºſſ ſuſ ºw s º , ºff" ſº % %–22% |E= yº º // "º) // *--zº’--— & sº _^{ FIGURE 99. Split-thickness graft. It is difficult to cut uniform grafts freehand; the use of the mechanical dermatome gives excellent uniform results. the skin of the thigh, which was held taut by boards or suction boxes. More recently the combined ingenuity of surgeons and in- strument makers has produced a variety of instruments designed to provide perſect grafts of uniform thickness in large sheets. The most popular of these is the Padgett-Hood dermatome, a half circle drum provided with a cutting blade which is moved back and forth at a calibrated distance from the surface of the drum, to which the skin adheres. Split-thickness grafts furnish ideal covering for a great variety of defects and are particularly useful in burns. Here they are planted in Continuous sheets or are cut into small squares and seeded on granulations after the fashion of small deep grafts. In a study carried out during World War II, furthermore, it was found that a split graft could be made to grow on the granula- tions in osteomyelitic bone cavities. These “skin dressings” greatly hastened healing and the control of infection. Pedicle Graft. Occasion frequently presents for the transplanta- tion of large portions of skin with the underlying fat and sup- NURSING IN PLASTIC SURGERY 361 porting connective tissues. Such grafts cannot at any time be isolated from the blood supply. In order to accomplish this transfer the operation must be carried out in stages which per- mit a new blood supply to be established from a new source before the original one is severed. Such operations may assume great complexity depending upon the demands of a particular plastic problem. For example, when tissues are torn from the dor- sum of the hand and the extensor tendons lie bare and exposed, the viability of those tendons and the function of the hand can be preserved only by early covering with full thickness skin and fat. A large defect of the forearm may demand the same type of covering before a necessary bone graft or muscle transplant can be done. In many extensive wounds large areas of scar tissue must be replaced by healthy normal skin before additional operations can safely be performed on the deeper structures. In a wide va- riety of such lesions successful covering is obtained through the use of the single pedicle flap. The skin and fat of such a flap are elevated on the abdominal wall or elsewhere; it is essential to preserve a portion of its attachment through which pass the blood vessels nourishing the flap. The free portion is sutured to the re- cipient area but remains temporarily dependent on the existing blood supply through the pedicle. After two or three weeks new vascular channels will have become established between the flap and the new structures to which it has been sutured, permitting the severance of the pedicle. This division is carried out in stages or in a single procedure, depending upon the size and shape of the flap and the condition of the tissues. The stump of the pedicle is sutured back into its bed. If the flap thus elevated is reasonably narrow, the donor defect can sometimes be closed immediately by undermining the surrounding skin and taking advantage of its elasticity. Larger donor areas must be covered by split-thick- ness grafts. Tubular Pedicle Grafts. These are among the safest and most useful of grafts and are especially dependable when full-thickness skin and fat must be transplanted to a distance from the donor site. They have an advantage over the simpler forms of pedicle flaps in that at no time during their transfer is any open area exposed. These tubed pedicles are usually constructed on the ab- domen, although they are sometimes made on the flank or on the back, and smaller ones may be built from the skin of the arm or leg if these tissues are sufficiently relaxed. There are several methods by which they are constructed. All are variations of the 362 SURGERY OF THE INTEGUMENTARY SYSTEM FIGURE 100. Pedicled flap graft. A, A flap of skin and subcutaneous tissue are elevated; B, the resulting defect is closed; C, the flap is sutured in position where needed, in this instance on the back of a hand. original method in which staggered parallel incisions are made, the intervening flap is elevated, and the surrounding tissues are widely undercut. The lateral margins of skin are then sutured together beneath the central ſlap; the flap forms a roll or tube of skin and its edges are sewed together. The resulting graft re- sembles a satchel handle with circulation supplied from both ends. After twelve to twenty days one end or the other can be closed off with a rubber tourniquet to test the adequacy of the circulation passing through the opposite pedicle. When it is ascertained that the flap remains of good color and is viable throughout, the end closed by the tourniquet can be severed and reimplanted at any desired site. Such a flap may be transferred directly to the recipient area or may be moved anywhere in the body, moving first one end and then the other. A convenient method attaches one end of the flap to the hand or wrist, from which it can be carried elsewhere ſor ultimate implantation. Segments of healthy skin measuring 10 by 25 centimeters are NURSING IN PLASTIC SURGERY 363 readily available from the average adult, and much larger flaps have been constructed. Postoperative Care From the standpoint of nursing and postoperative care, plastic procedures necessitating skin grafting are apt to be exacting. Pedicle flaps must be protected against pressure and must be watched for signs of impending ischemia (scarcity of blood) and necrosis. Frequently the adjustment of a dressing or the removal of a few constricting sutures will save a threatened flap. Serum or pus gathering beneath a split graft separates it from its nutri- tive base and must be removed. Flaps in the process of transfer must be watched for strangulation. Infection must always be guarded against, and prophylactic measures using sulfonamides or penicillin are recommended. All dressings are done aseptically with the surgeon and assistants masked. Grafts are often helped in their struggle for survival by the use of sterile compresses moistened in warm normal saline solution. THE TREATMENT OF DEFORMITIES A wide variety of deſormities are correctable by plastic sur- gery. Many of these deformities are congenital, others are acquired as a consequence of injury or disease. Surgery for cos- metic reasons alone is frequently justifiable; the healthy person of pleasing appearance should be careful not to underestimate the effect upon another's personality of an obvious deformity, even though the deſormity causes no physical disability. A child's entire social development may be improved by a single operation which converts abnormally protruding ears into close-set ones. Satisfactory technics have evolved for reconstructing noses, ears, lips, and eyebrows. Congenital deformities of the hands and feet are common. Extra fingers or toes (polydactylism) are removed. Webbed fin- gers or toes (syndactylism) are treated by division of the web in such a manner as to preserve the function and skin of both digits. It is interesting that both of these conditions are hered- Itary. MAXILLO-FACIAL SURGERY The development of plastic surgery has greatly widened the scope of this field. Perhaps the most notable application has been been directed toward oral surgery for malignancy. Cancer in- 364 SURGERY OF THE INTEGUMENTARY SYSTEM volving the tongue and mouth raises serious problems in removal and reconstruction. The sacrifice of a portion of the mandible together with the removal of part of the floor of the mouth or a large portion of the cheek represents only the beginning. These defects must be closed, and the closure must be acceptable from a functional and from a cosmetic standpoint. Such procedures often necessitate the provision of pedicle grafts lined with epi- thelium to provide coverage not alone for the exterior but for the oral cavity as well. Metal splints or bone grafts are required to replace portions of the mandible or maxilla. Dentures have an important role in such reconstruction. And very often these ex- terior operative procedures must have added to them wide dis- section of the lymph nodes on one or both sides of the neck, removing all tissues partaking in the metastatic pathways of oral C2 ITCCT. COSMETIC SURGERY The cosmetic aspects of plastic surgery are perhaps less im- portant in a sense than the correction of congenital defects or the excision of tumors. Even so, they may assume grave importance. The author recalls a famous actress whose career on the stage was prolonged by a “face lifting” procedure which restored her youth- ful appearance. Recently, technics have been developed to over- come the unsightly pitting of the skin secondary to acne. Curi- ously enough, such scarred and pitted skin can be rendered smooth and quite normal simply by sanding its surface much as one would smooth a roughened piece of wood. To this same category belongs mention of rhinoplasty. These are operations on the nose designed to straighten those which are Crooked, to re- move unsightly bumps or to build up defects in the nasal bridge with grafts of cartilage. Such defects may, of course, be congenital or acquired. In either case, this correction may have bearing not only on the appearance of an individual but on his acceptance in society, his earning capacity, and his self-esteem. The plastic surgeon may find himself confronted with prob- lems in urology, gynecology and Orthopedics. He may have to construct a vagina which is congenitally absent, or he may have to build a urethra in a patient with hypospadias. He may be faced with a congenitally malformed or traumatized hand in which a thumb is missing and for which transference of bone, tendons, nerves and blood supply as well as skin is needed. Indeed, the potential challenges are endless, and the results are limited only NURSING IN PIASTIC SURGERY 365 by the capacity of human physiology and the ingenuity of the surgeon. Occasionally, following trauma or as the result of an operation for cancer, a facial mutilation is too extensive for successful re- construction. In such a case the appearance of the patient can be greatly improved by the construction of a prosthesis (mask or other artificial replacement). The skill of the prosthesis-maker is such that very close scrutiny is necessary to detect the difference between the real and the artificial. MAMMAPLASTY The nurse should have an appreciation of the mental and physical aspects of the patient with mammaplasty so that she may give effective nursing care. Tremendously hypertrophied breasts, such as in virginal hyper- trophy in a young girl or very large and pendulous breasts of an older woman, definitely affect the personality. Also they are a definite handicap by virtue of the excessive weight and will pre- vent in engagement of sports and other activities. Often there is evidence of an inferiority complex. Self-consciousness and re- luctance to meet social and business obligations are probably the most obvious characteristics. There is difficulty in fitting clothes; the young girl is not able to wear the styles in clothing that are becoming to other girls. The brassiere must be specially made to fit properly; other gar- ments must be made to order or altered when ready-to-wear ap- parel is purchased. The weight of the breasts puts added strain upon the shoul- ders. There is difficulty in preventing the brassiere straps from pressing deeply into the skin. Backache, poor posture and kypho- sis are complications which develop when the condition is per- mitted to persist. The operative procedure is usually not recommended when only an improvement in personal appearance is sought but the conditions mentioned above often make it a necessary procedure. The nurse should be kind, pleasant and tactful in her approach So that the confidence of the patient may be won as soon as pos- sible. The routine of the ward should be explained. She should understand that various doctors routinely examine all patients in the hospital so that when she is examined she will not think She is subjected to curious gazes. It should be remembered that she is much more sensitive than the average patient. 366 SURGERY OF THE INTEGUMENTARY SYSTEM Preparation for operation is similar to that for general anes. thesia. The operative area should be prepared in the usual man- ner. Skin marking with brilliant green to outline the operative site is usually done by the surgeon the day before operation. The operative region is dressed with a large pressure dressing. Drains, when used, are removed by the surgeon after the first twenty-four hours. Signs and symptoms of hemorrhage and in- fection should be reported to the surgeon. The patient is usually gotten out of bed the second or third day. Several large packages of sterile mechanic's waste are the only additional supplies necessary to do the first dressing. This is done about the fifth or sixth day unless drains have been inserted at the time of operation. The surgeon usually removes the sutures about the tenth day and the patient is discharged about the twelfth day. Before the patient leaves the hospital the nurse should make certain that she understands the type of brassieres to wear. The surgeon usually advises her to wear a good supportive brassiere day and night for six months. The brassieres should be made of tightly woven material such as nylon or fine broadcloth and double thickness of material used whenever extra support is necessary. The sleeping brassiere is made in the usual manner with the additional feature of lacings under the arm so that it may be adjusted when the patient is lying down. These bras. sieres should be specially made, and vary in price according to the different corsetières and the choice of material. Until the brassieres are made a properly applied elasticized bandage gives the necessary support. A member of the family should be in structed, along with the patient, in the application of the ban dages before the patient is ready for discharge. The mental state of the patient seems to improve greatly after the operation; she is happy that the procedure is completed and does not seem to be worried about meeting people. The adjust. ment to society seems to be fairly easy because she no longer feels that she appears a “freak” to others. NURSING CARE IN PLASTIC SURGERY The preoperative and postoperative nursing care of these pa. tients involves all the same principles which have already been discussed in connection with the care of patients having other types of surgery. There are, however, certain additional features which need particular attention. These are: (1) the personality problem which nearly always is present in patients who are hav- NURSING IN PLASTIC SURGERY 367 ing plastic surgery; (2) the special care of the various kinds of grafts which are employed; and (3) special care necessitated by the special region of the body involved, as in operations about the mouth and neck. Plastic surgeons are often as much artists as scientists, and each will have his special preferences as to the de- tails of care. For that reason, it seems more appropriate to outline here only the principles involved. Before operation the nurse must spend sufficient time with the patient to gain insight into the patient's personality, his hopes and fears, and his way of reacting to stress. At the same time the nurse must start to orient the patient's thinking toward recovery and the assumption of an active place in the world about him. This can be of more value than a successful outcome to the opera- tion. The nurse must learn to be unaffected by the most hideous deſormities, so that the patient can realize that his appearance does not prevent him from enjoying ordinary or normal relation- ship with other human beings. In the case of the patient who presents a long-term problem, perhaps necessitating multiple procedures during one long or several hospital admissions, it is well for the surgeon and nurse to develop a detailed plan for the care of the patient. This should include indoctrination of the patient and his family, suitable oc- cupational or diversional therapy, as well as the plan for re- habilitation. As an example, the case of a patient who had sus- tained a serious destructive injury to the hand might be consid- ered. At first, the problem of reassurance would be paramount. Next would be the problem of keeping up the morale of the patient while he was undergoing the multiple procedures needed to construct as useful a hand as possible. Finally, would come the job of re-training the patient so as to enable him to earn a liv- Ing in a new way. There are certain basic considerations applicable to the care of all grafts. Motion is undesirable since it prevents the graft ſrom acquiring the new blood supply it needs. Infection is dis- astrous since bacteria can kill the cells of the graft. Bleeding is harmful for it may separate the graſt from the recipient area. The surgeon may ask the nurse to observe the circulation in a flap or pedicle graft; if she sees blanching or cyanosis, the surgeon is to be notified at once. Most plastic procedures are surface operations, so that the pa- tient, iſ he has not lost too much blood, will not be sick. There will be no impairment of his respiratory, alimentary, or urinary 368 SURGERY OF THE INTEGUMENTARY SYSTEM tract functions. This is not the case following maxillo-facial surgery, and the special care needed in this field has been out- lined on page 208. SUMMARY Plastic surgery is concerned with the repair of surface deformi- ties, whether these be congenital, traumatic, due to disease, or due to procedures intended to cure disease. Most of the patients will have personality problems, and many will need extensive re- habilitation. Immobilization of wounds and grafts, the Control of hemorrhage, and the avoidance of infection are of the utmost importance in this field. VOCABULARY REVIEW keloid rhinoplasty mammaplasty Z-plasty dermatome syndactylism pilonidal pedicle graft split-thickness graft maxillo-facial SUGGESTED READING 1. Barsky, Arthur J.: Principles and Practices of Plastic Surgery. Baltimore, Williams and Wilkins, 1950. 2. Brown, J. B., Byars, L. T., and McDowell, F.: Preoperative and Postope, a tive Care in Reconstructive Surgery. Arch. Surg., 40:1192–1210 (June) 1940. 3. Brown, J. B., and Cannon, B.: Repair of Major Facial Injuries. Ann. Surg., 126:624–632 (October) 1947. 4. Brown, James Barrett, and McDowell, Frank: Skin Grafting. 2nd Ed. Phila delphia, J. B. Lippincott Co., 1949. 5. Christopher, Frederick: Textbook of Surgery. 5th Ed. Philadelphia, W. B. Saunders Co., 1949, pp. 1403–1438. 6. Krause, Marie V.: Nutrition and Diet Therapy. Philadelphia, W. B. Saun- ders Co., 1952, pp. 222–228. 7. Lewis, G. Kenneth: Early Care of Traumatized Hand with Pedunculated Flaps. Am. J. Surg., 79:660–666 (May) 1950. 8. Pearlman, Louis M.: Plastic Surgery. Am. J. Nursing, 51.618–620 (October) 1951, CHAPTER 31 The Care of Burns Perhaps no single agent has been more useful or longer known to man than fire. No doubt human burns, an undesirable by- product of this agent, have been observed and studied from man's earliest times. As the twentieth century progresses, the problem grows increasingly complex. While, on the one hand, there rises a greater understanding of the pathologic physiology of human burns, man's ingenuity, on the other hand, devises more and more potent means of destroying himself. Burns are wounds resulting from exposure to heat, chemicals, electricity or radioactive agents. They can be classified as to de- gree on the basis of the amount of tissue damaged or destroyed. This involves not only an estimate of the percentage of body sur- face which has been burned but also of the depth of destruction of the involved tissue. An experienced observer can make such an estimate with reasonable accuracy from the initial appearance of the wounds. Determinations of this nature are important in planning therapy and in making individual prognoses. For Con- venience burns are divided into first, second and third degree. First degree burns are those in which exposure has been mild. On inspection, they present only erythema of the skin. The injury is confined to the most superficial layers of the epithelium which may be cast off in the healing process. Mild sunburn and wind- burn are of this type. Second degree burns are deeper and pro- duce blister (bleb) formation, but elements of the epithelium remain undamaged beneath the surface and are capable of growth and regeneration of the integument in the healing process. In third degree burns there is total destruction of the skin and, occasionally, of the deeper structures, and charring of the tissue occurs. All degrees of burns may result from varying amounts of ex- posure to any one of the necrotizing agents, and in general, most burned patients present areas involved in at least two and some- times in all three degrees. In addition, they commonly have wounds of other types such as fractures or lacerations. The respiratory system may be involved through the inhalation of 369 370 SURGERY OF THE INTEGUMENTARY SYSTEM smoke or through actual burning of the lining of the trachea and bronchial tree. These added injuries serve to complicate the treatment of any given individual and, of Course, may add dan- gerously to the gravity of the overall picture. For the purpose of clarification discussions of therapy here will be confined solely to the burn itselſ. With the exception of burns resulting from contact with chemical agents in which case a wound caused by an acid may be neutralized by an appropriate alkaline substance, a description of the treatment of thermal burns suffices for all types. In general, it seems wise to divide therapy into three stages: the initial period, the supportive period, and the reconstructive period. THE INITIAL PERIOD An extensively burned individual presents simultaneously many problems. First of all, there is the wound itself. Burn wounds are occasionally relatively clean bacteriologically; one example is that which results from scalding. More often they are prone to be grossly contaminated by fragments of clothing, oil, grease, street dirt, or by well-intentioned, but harmful, home remedies. In addition to bacteria already at the site of such a wound further contamination may come from the hands and from the nasopharynx of anyone else in contact with the patient. Ideally, the first attention to these wounds should be adminis- tered by individuals who are masked, gowned and gloved, and who are operating under the most scrupulous sterile technic. The wounds are mechanically debrided and ſrequently may be rendered cleaner by repeated gentle irrigations with normal saline solution. The free use of soap and water or some other detergent to the wound is often helpful. Closed Method. Once these preliminary preparations have been made, one must choose between two general methods of caring for the wound. The first and most popular is the so-called “closed method” in which the wound is encased in sterile dress- ings and completely excluded from its environment. For this purpose a thin layer of fine mesh gauze impregnated with petro- latum or some similar substance is applied to the wound. This is in turn covered by an abundance of absorptive gauze, perhaps with the addition of some substance similar to mechanic's waste. The whole is then enclosed in a firm binder designed to provide an elastic type of support and compressing the involved tissues THE CARE OF BURNS 37] within a bulky dressing. Elastic bandages serve this purpose well. The dressings must be applied rapidly but with great care, for they are meant to be left undisturbed for a week or more. Ex- tremities are often splinted. Burned hands and fingers should always be supported securely in a neutral position. This type of therapy is excellent for the extremities, but for the trunk, face and abdomen it is apt to be less useful. Open Method. The face, and especially the genitalia and perineum, adjacent as they are to bacteriologically contaminated body orifices, are almost impossible to dress satisfactorily. For them, and in the hands of some surgeons for all burns, the so- called “open method” of treatment has advantages. In the open method, following mechanical cleansing, an effort is made to pro- duce an eschar to cover the wound and to act, in a sense, as a protective dressing. Many substances have been tried. Tannic acid alone or in combination with silver nitrate, gentian violet, triple dye, and others have all had their supporters. More re- cently, sprays of triethanolamine and similar agents have been employed. To these have been added solutions of antibiotics for local application. The newer of these substances have the ad- vantage of producing a thin, pliable eschar which is transparent and through which the progress of the underlying burn wound can be observed. Patients treated by the open method must lie on sterile bed linen, must be protected from contact with bedcloth- ing, and must be kept warm. It seems to the writer that a happy solution of the problem of which of the methods to use is to be guided by circumstances and to employ either or both in response to the demands of the extent, location and character of the injury. Burn Shock. While the wound is receiving its inital care, si- multaneous attention must be afforded to other aspects of the patient's condition. Measures to control pain must be instituted at once. This is accomplished usually with morphine or one of its derivatives. These can, and frequently should, be administered intravenously in order to secure a prompt response. The problem of pain control becomes much easier once dressings have been applied or a protective eschar produced. Burn shock must be considered from the first. The entire mechanism of this phe- nomena is not known, but there are certain basic phenomena in its production which are understood. In a burn there occurs an immediate outpouring of large quantities of serum from the cir- 37.2 SURGERY OF THE INTEGUMENTARY SYSTEM culating blood into the injured tissues. The walls of the capil laries undergo changes which permit this diffusion of serum into the tissues and out of the circulating blood. There is a Corre. sponding reduction in blood volume, and the blood which still does circulate becomes concentrated. In this state the blood becomes thick and viscid with a preponderance of cellular ele- ments in a reduced fluid medium. These changes occur regularly in burn shock and produce restlessness, tachycardia, shallow res. pirations, apprehension and a falling blood pressure. The failure to excrete urine in adequate amounts often presages death. In an effort to combat and control this shock stage, those substances which have been lost to the circulating blood must be replaced by intravenous therapy. For this purpose, blood plasma or one or another of its substitutes (plasma expanders) is used gen erally. The volume required over the course of the first day or two in an extensive burn may be enormous. Elaborate formulas have been devised to predetermine the plasma requirements. These are based on an accurate estimate of the percentage of the body surface which has been involved in the burn. Fluid require- ments may also be ascertained by hourly hematocrit determina- tions, which measure the changing degree of hemoconcentration and give indication of the desired rate of plasma administration. The intravenous administration of saline and glucose Solutions is also indicated to a limited extent in severely burned patients, although alone these solutions are of little value in Combating shock. Fluid requirements of this sort are best met by oral intake on the part of the patient; this is usually possible. Occasionally, in this initial stages of therapy whole blood transfusions are in- dicated and desirable, although for the most part, these are more useful at a later stage when anemia develops. Antibiotic Therapy. Efforts to Combat infection must never be neglected. These also are measures which should be instituted at once. While some forms of therapy are based on the inclusion of antibiotics in the wound dressing itself, a more effective program appears to follow the oral or intramuscular route of administra- tion. Tetanus antitoxin, or toxoid, is given. Disaster Teams. It will be apparent that numerous demands in therapy must be met simultaneously in treating these patients in the initial stages of their injuries. To meet these demands and to facilitate rapid, gentle and efficient care many institutions have wisely formed “burn teams” specially trained for this work. In THE CARE OF BURNS 373 Granulation tissue FIGURE 101. Regeneration of the epithelial surface of the skin after a severe burn. the event of disaster such arrangements would be of inestimable value. THE SUPPORTING PERIOD This might be said to begin when the patient has survived the initial trauma and begins to recover from his injury. In this period, the wound may heal completely if it is first or light sec- ond degree in character. Second degree burns will usually mani- fest evidence of healing in a week or ten days. Epithelial islands rise from the depths of the skin (so-called rete pegs) and begin to proliferate across denuded areas. If the burn has not been too deep and if infection has destroyed additional tissue and thus interfered with the reparative process, this type of skin coverage may be entirely adequate. When the burn has been more exten- sive, approaching or actually third degree, skin grafting pro- cedures become necessary. These are undertaken at the earliest possible time, often in seven to ten days, and may coincide with the first dressing of patients treated by the closed method. Of the available types of grafts, the best for this purpose are of the split thickness variety. Sheets of skin are cut, by means of a calibrated instrument (dermatome), from uninjured surfaces for transfer to the granulation tissue covering the burned sur- faces. Delay and infection are responsible for excessive over- growth of granulation tissue and for the development of large amounts of scar tisue. Scar deformities and constriction ensue. 374 SURGERY OF THE INTEGUMENTARY SYSTEM Such changes in the hand or forearm interfere with the function of underlying moving parts such as joints and tendons. Function is best retained by early grafting and adequate skin coverage. Numerous attempts have been made to transfer skin from one individual to another. With the exception of identical twins, in whom the method has met with success, such grafting pro- cedures have always failed. During this same period, the nutritional state of the patient must be maintained by adequate diet. It is usually felt that an intake ranging from 3000 to 3500 calories a day for the average adult is preferable to a greater intake which might result in anorexia, vomiting, and distention. Diets high in protein and vitamin content are desirable, and the oral route may be aug. mented by parenteral administration. Antibiotic therapy must be continued; organisms which may be resistant to those agents in use reappear, necessitating a change to another antibiotic. Fluid and electrolyte balance are watched to assure adequate urinary output without permitting edema to develop. Derange- ment of potassium balance, indicated by weakness, lassitude and characteristic electrocardiographic changes, occasionally neces. sitates the inclusion of potassium in parenteral therapy. This is also the stage in which anemia Commonly appears, necessitating blood replacement by transfusion with whole blood or with washed red cells. Iron, liver and vitamin B12 may be utilized to hasten an individual's own hematopoietic response. It is also in this period that the so-called “toxic state” is en- countered. Here, probably because of widespread infection in an extensive burn wound and as a result of absorption of dead tissue, profound alterations may appear in the patient. Fever, tachycardia and asthenia are commonly encountered. Liver fail- ure, sometimes associated with renal failure, is apt to prove fatal. Survival from the initial trauma may be followed by death in this second period, or this period of support may be drawn out for many months. In a sense, it extends up to the time when skin Coverage of the wounds nears completion. Since homografting (from one individual to another) is not successful, the surgeon must use the patient himself as a skin donor. Ofttimes he is hard put to find sufficient and suitable sites from which skin is avail. able for coverage. In these circumstances, partial coverage is af. forded by “postage-stamp” grafts or by Davis grafts (small, deep grafts), depending on those isolated islands of skin to proliferate and Coalesce. Many times warm sterile saline compresses or sur- THE CARE OF BURNS 375 gical removal of eschar or both are necessary to prepare denuded surfaces for grafting procedures. RECOVERY PERIOD The chain of events heretofore mentioned gradually merges into the final or recovery period. This is a time of convalescence and rehabilitation during which the survivors regain lost weight and strength and in which function is restored. Despite vigorous efforts aimed at their prevention, scar contractures may appear across joints, in the axilla, between the chin and thorax, and in similar locations. At this stage, the ingenuity of the plastic surgeon may be necessary to improve and correct these defects. In the instance of extensive facial burns, it may be necessary to construct portions of the nose, or of ears, or to build eyelids and eyebrows. A stenosed mouth may need opening, and lips may have to be constructed. Many of these reconstructive pro- cedures are accomplished only through multistaged operations requiring great skill and patience on the part of both surgeon and patient. These patients may require untold aid to regain their morale before they can face the world and resume their oc- cupations. The services of physiotherapists and occupational therapists are of importance in helping the Crippled to overcome stiff finger joints or in learning to walk again. Occasionally, a severe third degree burn of a foot or leg may require amputation and necessitate the provision of a prosthesis. Lafe Sequelae of Burns. Years after the trauma a burn Scar may ulcerate, and the involved tissue may be found to have un- dergone malignant changes. This is particularly true of x-ray and radium burns. Many of the early workers in roentgenology, unaware of these dangers, fell victims to these often fatal lesions. The mechanism of metaplasia from a burn scar to epithelioma is poorly understood. It appears that the thin, scarred, and poorly nourished epithelium which regenerates to heal some burns is poorly equipped against stress, stretching, and pressure, and tends readily to break down and ulcerate. Such a process re- peated over and over again is prone to become chronic, resistant to therapy, and finally malignant. BURNS RESULTING FROM ATOMIC ENERGY Exposure of even momentary duration to the enormous amount of heat and other forms of energy resulting from nuclear fission produces most devastating injuries. Human beings suſ- 376 SURGERY OF THE INTEGUMENTARY SYSTEM ficiently close to an atomic explosion are lethally burned; those somewhat more remote may escape thermal burns of severity but suffer from the effects of radiant energy of shorter wavelengths. Needless to say, injuries of other varieties also occur, incident to the effect of the blast. Specific means of therapy are lacking. In addition to the usual burn therapy, strenuous antibiotic therapy and transfusion of blood are used. NURSING CARE OF BURNED PATIENTS The nurse should be prepared to help the surgeon when a burned patient is admitted to the hospital by anticipating the need for morphine and supplying everyone in attendance with masks, gowns and gloves. The patient's clothing should be re- moved carefully, being cut wherever necessary. Rings should be removed; if edema prevents their removal they should be taken off with a ring cutter. Careful record of all fluids and treatments administered should be begun at once. Aſter the surgeon has completed the initial dressing the patient should be placed in the kind of bed that will facilitate the best nursing care. For a severely burned patient a fracture bed, supplied with a sponge- rubber mattress, is useful, as it makes the handling of the patient and the use of the bedpan easier. All in attendance on the patient should wear masks. Frequently there are delirium and incontinence of urine and ſeces. At times, when the thighs are burned or when he antici- pates incontinence, the surgeon inserts an indwelling Catheter to prevent soiling of the bandages and for the more accurate de- termination of the amount of the urinary output. Fluids should be forced. The diet should be as high in caloric and vitamin Content as the patient will tolerate. The removal of the dressings is difficult when the burn is ex- tensive and severe. A portable bathtub half filled with warm water or normal saline solution should be placed by the bed to provide for the immersion of the patient. In this way the dress- ings can be removed more quickly and with less pain. It should be realized that it is often a healthy man, a busy housewife, or an active child who is burned. The burned patient is suddenly converted from an active individual into a bed- ridden one. He is ſearſul and emotionally upset. Since the process of healing is slow, various phases of mental depression are usually THE CARE OF BURNS 377 encountered. Winning his confidence and offering constant re- assurance will help to keep up his morale. Too many visitors should be guarded against; they must be prohibited if they seem to upset him. Whenever possible, and as quickly as possible, oc- cupational therapy should be instituted. The problems of nurs- ing care are usually solved more easily when the patient's morale is comparatively normal. SUMMARY A burn is a destructive wound of the skin, and sometimes of the deeper tissues, caused by heat, other forms of radiant energy, and chemicals. If more than a small portion of the body is in- volved, there are systemic effects of a serious nature. Large num- bers of severely burned patients may be one result of a disaster; communities and their hospitals should be organized and pre- pared to meet such an emergency. VOCABULARY REVIEW hemoconcentration CO77 tº a Ciºlºre burn-shock eschar blebs nuclear fission SUGGESTED READING 1. Curtis, Artz, et al: The Problem of Burns in Disaster. U. S. Armed Forces Med. Journal, 4:39–48 (Jan.) 1953. 2. Cooper, Lenna F., and Barber, Edith M., and Mitchell, Helen S.: Nutrition in Health and Disease. Philadelphia, J. B. Lippincott Co., 1950, pp. 389–390. 3. Evans, Everett Idris: The Early Management of the Severely Burned Patient. Surg, Gynec. & Obst., 94:273–282 (Mar.) 1952. 4. Morton, John H., Kingsley, Harry D., and Pearse, Herman E.: Studies on Flash Burns: The Protective Effects of Certain Fabrics. Surg., Gynec. & Obst., 94:497–501 (March) 1952. 5. Peterson, Grace G.: A Method of Treating Burns. Am. J. Nursing, 50:785– 786 (December) 1950. 6. The Emergency Treatment of Burns. Am. J. Nursing, 53:179–182 (Feb.) 1953. (Released by Federal Civil Defense Administration.) 7. Levenson, S. M., Davidson, C. S., Lund, C. C., and Taylor, F. H. L.: The Nutrition of Patients with Thermal Burns. Surg., Gynec. & Obst. 80:449-469 (May) 1945. CHAPTER 32 Surgery of the Breast Anatomy and Physiology. In order to understand the diseases of surgical interest associated with the breast it is necessary to consider briefly the normal development and physiologic changes which take place in this complex organ. The breast arises in the embryo from an epithelial thickening and bears a close relation- ship to sweat glands. Sexual differentiation, with stimulation to growth in the female, is accomplished in adolescence under hormonal influences. The gland rapidly achieves a high degree of specialization with pronounced physiologic variations which are responsible for many of the interesting clinical entities which are seen by the surgeon. Grossly, the breast varies in appearance not only with sex but also in respect to age and in response to the general physiologic changes associated with puberty, menstruation, and pregnancy. Variations in position and number also occur as evidenced by the not infrequent appearance of supernumerary breasts (polymas- tia). Such accessory breasts may be found anywhere along the milk line, between the inguinal region and axilla, as in quad- ruped mammals. They occur as single or paired imperſect organs above or below the normal ones, and they are of no clinical sig- nificance except for the aberrant breast which sometimes appears in the axilla, where it seems especially prone to develop into car- cinoma. Total absence of one or both breasts is of extreme rarity, although occasionally the nipple ſails to develop or matures im- perfectly. Deformities of the nipple (cleſt, inverted or otherwise malſormed) are significant only as they interſere with nursing. The average breast is composed of fiſteen or twenty lobes, each of which contributes a duct directed toward the nipple. These branching ducts terminate in numerous acini or glands, and the entire structure is imbedded in ſat which is in turn supported by a framework of connective tissue. The nipple is a relatively tough, rubbery structure providing an exit for the major tubules formed by the confluence of the ducts arising ſrom the lobules. Surround- ing the nipple is the areola in which, as in the nipple, there is an abundance of erectile tissue. This tissue contributes to the erec- 378 SURGERY OF THE BREAST 379 tion of the nipple in response to the stimulation provided by the act of nursing. The breast has a generous blood supply and is richly supplied with lymphatics, which ramify about the acini and ducts. The majority of the lymphatics drain toward the axilla along the pec- toral fascia, but the upper and medial quadrants of the breast are drained along the perforating lymph vessels directly into the thorax. Other lymphatic pathways lead into the mediastinum and even cross the midline to communicate freely with those of the opposite breast. They are of extreme importance in the con- sideration of the proper surgical approach to carcinoma arising in the breast. It is through these channels that the malignant cells are disseminated at an early stage in the disease, and only by their radical removal together with that of the breast can there be a prospect of effecting a cure. The breast is subject to functional change and aberration as much as any structure in the body as it responds to the hormonal stimulation secondary to puberty, menstruation and pregnancy. During adolescence the ſemale breast grows in mass chiefly as the result of an increase in the ſat and connective tissue Com- ponents with slight change in the volume of the secreting mecha- nism. Before each menstruation a change occurs which is charac- terized in most women by discomfort and a sense of engorgement. There may even be a slight discharge from the nipple. These un- comfortable symptoms are the result of a temporary proliferation of epithelial components, both glandular and ductile, and they disappear with the progress of menstruation. With the onset of the menopause and the concurrent cessation of hormonal stimula- tion, the breast undergoes involution and atrophy. In pregnancy the glandular elements of the organ hypertrophy in preparation for lactation. The hormone prolactin from the anterior pituitary is responsible for the production of milk ſol- lowing delivery. Involution of the breast takes place following the Cessation of nursing, lactation ceases, and the breast again becomes subject to the changes associated with the menstrual Cycle. Aberrations from these normal functional changes form an interesting group of conditions. In this category falls the phe- nomenon of witch’s milk which appears briefly in newborn in- fants whose breasts, under the influence of the maternal pro- lactin, secrete small amounts of milklike fluid. Milk may also appear briefly at puberty in either sex (puberty mastitis). In the 380 SURGERY OF THE INTEGUMENTARY SYSTEM male, enlargement of one or both breasts during and following puberty results in the condition known as gynecomastia. This enlargement often subsides spontaneously but may remain to constitute a source of embarrassment and discomfort. Surgical intervention is indicated only for cosmetic reasons. In the adoles- cent female the normal enlargement of the breasts may be ab- normally continued to produce the so-called virginal hyper- trophy. In this condition the breasts sometimes become extremely large and are uncomfortable, unwieldy and embarrassing. Se- vere cases are treated by the plastic surgeon (mammaplasty, page 365). DISEASES OF THE BREAST Diseqses of the Nipple When there are developmental defects with retraction, it is often possible during the period of lactation to draw out the nipple with a breast pump, although occasionally it may be necessary to resort to a plastic operation. Most obstetricians direct their patients to prepare for lactation by massaging and oiling the nipples with the object of prevent- ing maceration and cracking. Cleanliness and dryness must be maintained. At times painſul fissures follow maceration of the nipple by the mouth of the inſant and provide a portal for the entrance of bacteria with resultant inflammatory disease of the breast it- self. Once a fissure becomes established, the nipple may be pro- tected in nursing by the use of a shield. The local application of bland ointments or of compound tincture of benzoin protects the breast and promotes healing. Tumors of the nipple are rare, although occasionally the sur- geon encounters a fibroepithelial growth. These are usually pedunculated; they are benign and are cured by local excision. Paget's Disease of the Nipple. This is a Carcinoma arising from the squamous epithelial cells of the nipple; it usually ap- pears in the fourth and fifth decades of life and is rarely seen in younger women. It begins as an eczematous lesion involving the nipple, the areola, and subsequently the cutaneous surface of the breast. The tissues are moist, retracted and raw, and bleed easily. Extension to the axillary lymph nodes of this epidermoid type of carcinoma follows in due course. Adequate treatment demands SURGERY OF THE BREAST 381 radical removal of the breast, pectoral muscles and axillary con- tents. The prognosis is somewhat better than in carcinoma aris- ing within the breast itself. Disedses Caused by Trauma Hemorrhage into the subcutaneous tissues or into the glandu- lar substance may result from blows upon or penetrating wounds of the breast and is sometimes differentiated from true neoplasms with difficulty. The history and the appearance of superficial ecchymosis are helpful in the diagnosis. In traumatic fat necrosis the differentiation from carcinoma can frequently be made only after microscopic study of the in- volved tissue. This lesion may present the same firm, painless mass with overlying skin retraction seen in malignancy. Diag- nosis is further complicated by the fact that many women who have possible cancer of the breast will recall some antecedent injury. Wounds of the breast usually offer no special problem unless the patient is lactating, in which case a fistula may occur and fail Inflammatory Disedses These are usually associated with pregnancy and lactation. Masłitis. So-called “caking” is a painful condition where ob- struction in the ducts interferes with drainage of the secreting glandular tissue. Swelling and engorgement appear in the affected portion of the breast, accompanied by an elevation in tempera- ture. The symptoms subside with the reestablishment of drainage through the duct system. However, should bacteria gain en- trance to such a lesion through a wounded nipple, acute mastitis with abscess formation may result. Most acute suppurative lesions of the breast are due to Staphylococcus aureus, and many can be successfully treated in the early stages by the administration of sulfonamides or penicillin. Unless the therapeutic response is prompt and complete, it is usually necessary to terminate lacta- tion. Abscesses lying deep within the substance of the gland tend to spread to adjacent lobules and to coalesce, with extensive de- struction of the mammary tissue. Surgical drainage is often neces- to close until lactation is terminated. The scar of a healed pene- trating wound sometimes obstructs a duct; the result of this is a retention cyst. Under these circumstances, should lactation occur, a milk cyst (galactocele) may form. 382 SURGERY OF THE INTEGUMENTARY SYSTEM sary when conservative measures fail. In such instances incisions into the breast should be made in a radial direction in order to avoid unnecessary severance of uninvolved duct structures. Mastitis is occasionally seen in adolescent girls and young adult women who have acute infectious parotitis (mumps). The re- sultant inflammation and tenderness, like that seen in the Ovary or testis, subside spontaneously but may leave the breast atrophic and Crippled. Chronic Suppurative Masłitis. This is at times the Sequal to acute mastitis when the causative organism is of low virulence. Recurring episodes of a mild inflammatory nature mark the course of this disease and are more prone to appear during menstruation. The administration of antibiotics together with hygienic measures often suffices for treatment, although open drainage may have to be resorted to. Tuberculous Masłitis. This is a rare disease. A tuberculous focus elsewhere in the body finds opportunity for dissemination in the actively lactating breast. Such a spread takes place through the lymphatics or through the blood stream to produce a diffuse process in the breast. Numerous cold abscesses appear and there is rarely invasion of the axillary glands. Removal of the breast may be necessary to bring about a cure. Cystic Disease of the Brecast Refertion Cyst; Galactocele. This may manifest itself in any one of several ways. The simplest of these is the retention cyst (p. 381) where material dams up behind an obstruction in a duct. A galactocele resembles this condition except that there the cyst is distended by milk. Each of these conditions is treated by simple excision of the cyst. Chronic Cystic Mastitis. This disease is frequently encountered in women at or near the menopause, when the breasts are under- going the involution characteristic of this stage of life, or in women in whom there is an endocrine imbalance. In general, there is an increase in the fibrous elements of the gland and atrophy of the secretory elements, and irregularities in these proc- esses produce a wide variety of pathologic changes. Cysts of varying sizes form behind obstructed ducts or arise as the result of degeneration of glandular components. Overgrowth is not necessarily confined to the fibrous tissue stroma but occurs as well in the epithelial structure. Occasionally a cyst grows to consider. able size and is referred to as a blue dome cyst. The result of SURGERY OF THE BREAST 383 these changes is the production of a “shotty” or “cobblestone” breast which is often tender and painful. Women with this dis- ease are apt to complain of unusual premenstrual hypertrophy and engorgement. As a rule the progress of the disease is slow. Usually both breasts become involved. Diagnosis. The differential diagnosis between chronic cystic mastitis and carcinoma is at times exceedingly difficult. There is statistical reason for believing that carcinoma arises slightly more often in the breast which is the seat of chronic cystic disease, and certainly, when cancer appears, its early recognition is rendered more difficult by the presence of the preexisting benign changes. The patient suffering from chronic cystic disease of the breast should submit herself for frequent examination by a competent surgeon who, in the event of the appearance of suspicious changes, should have no hesitancy in resorting to biopsy to de- termine beyond question the presence or absence of malignancy. In the milder forms of the disease, patients may be made comfort- able by wearing a firmly supporting brassiere. Occasionally sim- ple excision of the entire breast in older women is the procedure of choice. Neoplastic Diseqses of the Brecist The classification of tumors of the breast into benign and malignant types affords the best basis for their study and for de- cision as to correct treatment. New growths arise from any type of tissue found in the organ. Benign tumors are treated by local surgical excision, malignant tumors by extensive and radical operations which may be preceded or followed by deep x-ray therapy. BENIGN TUMCRS Adenofibroma. The commonest of the benign tumors is adeno- fibroma (fibro-adenoma, periductile fibroma, intracanalicular fibroma) which is seen most often in young women. This is usu- ally a solitary, firm, elastic, freely movable mass which is not ten- der. It grows slowly and occasionally becomes partly cystic through degeneration. Local excision is the accepted treatment. Papillary Cysładenoma. This is a tumor encountered only OC- casionally. It appears when the breast is functioning. Grossly it is Composed of a branching papilla growing out into a duct from a highly vascular base or stalk. The whole is encapsulated and originally benign. Attention is drawn to this lesion primarily by 384 SURGERY OF THE INTEGUMENTARY SYSTEM the discharge of blood or serosanguineous fluid from the nipple. At this stage delicate local excision with every effort to preserve intact adjacent ducts will suffice. Later, if untreated, the tumor may become malignant, assuming the clinical characteristics of adenocarcinoma. Occasionally the surgeon fails to locate the source of the bleeding when these tumors are too small to palpate or are less superficially located than is the rule. Under these cir- cumstances simple mastectomy is justifiable in Consideration of the malignant potentialities of the growth. CARCINOMA OF THE BREAST Carcinoma of the breast is the second most common malignant tumor in the female, only cancer of the uterus exceeding it in frequency. Most carcinomas appear in the fifth and sixth decades of life, although many are seen much earlier; Occasionally such a tumor is encountered in women in the early twenties. It develops also in the male. Women who have borne and nursed children seem somewhat more prone to malignant disease, yet sterility does not preclude malignancy. - Symptoms. These tumors appear insidiously and often grow to large size before they are noticed. Perhaps a blow on the breast calls attention to a growth, or it may be found in bathing or as an incidental discovery during general physical examination by a physician. These growths are neither painful nor tender. They are hard and blend with the surrounding tissue. Diagnosis. Of great diagnostic significance is the flattening and fixation of the overlying skin which results from lymphatic infil- tration by cancer cells. Superficially placed tumors may produce a small but visible dimple. In later stages of the disease the axil- lary lymph nodes are invaded and are palpable as hard, nonten- der nodules. Extensive axillary lymphatic involvement obstructs the normal drainage from the upper extremity and produces brawny elephantiasis of the arm. Some tumors grow as a large, superficial mass; others, of the scirrhous variety, cause irregular retraction of the breast tissue which appears to shrink en masse against the thoracic wall. When the skin is invaded by the ex- tension of the growth, it may assume the pitted appearance of orange peel (peau d'orange); or tiny nodules encircle the lesion and spread extensively, even to the other breast (lenticular car- cinoma, carcinoma en cuirasse); or the skin may slough and ul- cerate to present the bleeding, foul, secondarily infected surface of the tumor itself. Diagnosis is easy in the late and unfavorable SURGERY OF THE BREAST 385 stage, but is more difficult when the tumor is young and curable. Self-examination. In recent years an effort has been made to disseminate among lay people information about cancer which is designed to familiarize them with the presenting symptoms of the disease in various organs. With respect to the breast, women are urged to partake in a program of self-examination. This consists of a monthly inspection. The breasts should be examined first by looking in a mirror for dimples, swellings, depressions, retraction of the nipple, and so on. Such alterations frequently are best demonstrated by raising and lowering the arms. The woman then lies upon her back and carefully and gently palpates the breast on each side with the opposite hand. In this way, an in- telligent and observant woman may discover an abnormality at a very early stage. Then is the time to consult the surgeon for Con- firmation of the finding. The author makes it a practice to biopsy all breast tumors and to submit the tissue to the pathologist ſor examination. Such a schedule leaves no margin for error in diagnosis. Prognosis. The prognosis is determined by the degree of malig- nancy of the tumor, by the extent of the tumor when operation is undertaken, and by the thoroughness of the operation. Statistics vary, but in general only 30 per cent of patients operated upon for cancer of the breast survive five years or longer. In the cases of patients having tumors of low malignancy and without ex- tension to the axilla, however, more than three fourths can be permanently cured. The neglected patients, upon whom opera- tion is performed late in the disease, rarely survive, despite the most painstaking radical Surgery. Modern efforts toward the prevention and cure of cancer by the wide dissemination of information to laymen are worthy of wholehearted support. Success in the cure of cancer is directly proportional to the early recognition and treatment of the dis- ease. This is nowhere more true than in carcinoma of the breast. RADICAL MASTECTOMY The key to successful treatment of cancer of the breast lies in early and thoroughly radical removal. Such surgery is based on anatomic considerations with particular regard to the lymphatic pathways through which the cancer spreads. The skin is widely excised over the breast without regard to subsequent closure of the wound. The breast, pectoral muscles, and axillary lymph nodes and fat are removed en bloc. A skin graft may be required 386 SURGERY OF THE INTEGUMENTARY SYSTEM Stumps of pectoralia Tninor" and major \\\\ S$ Long thoracic N. ; # j Letíssimus dorsi FIGURE 102. Radical mastectomy. I, Line of incision; 2, the breast, pectoral muscles, and axillary nodes are almost completely removed; 3, closure of wound. to cover the central portion of the defect on the thoracic wall which results from wide excision of skin. The loss of func- tion of the arm following operation is relatively slight and unim- portant. RADIATION THERAPY Radiation therapy may temporarily heal and hold in abeyance an ulcerated growth. In some clinics it is felt that radiation ther- apy should be given preoperatively to help control the spread of the disease; elsewhere it is used postoperatively in an effort to kill any malignant cells disseminated during the operation or already lying beyond the limits of surgical removal. Still other surgeons feel that it is of little if any benefit and rely with Some justification on radical mastectomy alone. HORMONES AND BREAST CANCER The relationship between ovarian activity and breast cancer has long been recognized. It has been known, for example, that cancer arising in the breast of a pregnant woman or in one who is lactating is apt to assume greater virulence than under normal SURGERY OF THE BREAST 387 circumstances, growing more rapidly and metastasizing at a faster rate. In fact, many surgeons consider such tumors inoperable. In the treatment of metastatic spread from cancer of the breast, hormone therapy appears definitely to have a place. Never is it curative, but there is little doubt but that for a time, at least, it will arrest the growth of metastatic lesions. For this purpose the male sex hormone, testosterone, is employable and seems most helpful in bone metastases. Some investigators feel that diethyl- stilbestrol is more beneficial in soft tissue metastases. When tes- tosterone is used, the voice may deepen and hair may appear excessively on the face and body, demonstrating the masculiniz- ing potentialities of the drug. Patients receiving testosterone should be informed of these effects. Hormone therapy may be so effective as to permit pathologic fractures (at the site of a metastasis) to heal, and is often very helpful in relieving the pain associated with bone involvement. - METASTASES Breast cancer metastasizes commonly to the brain, to the skele- ton, the lung and pleura and, of Course, to skin, regional lymph glands and to the opposite breast. Prior to undertaking radical surgery in the form of mastectomy, it is always our routine to secure an x-ray examination of the lungs and thoracic skeleton. Complaints of back pain draw attention to the vertebral bodies which may be involved. Needless to say, the demonstration of remote metastases precludes radical mastectomy. The careful ex- aminer quizzes his patient in regard to metastatic involvement and eliminates the possibility of extension of the tumor before submitting a patient to operation. NURSING CARE There has been an increasing knowledge among the public about tumors of the breast. Through the efforts of the National Cancer Institute, The American Cancer Society, the radio, tele- vision and press, women are learning that the hope of cure lies in early recognition of the tumor followed by accurate diagnosis and adequate treatment. Women are being urged to examine themselves once monthly, at the end of the menstrual cycle, to discover any tumor in its earliest stage of growth. Fortunately, more women are now seeking treatment earlier and there is be- ginning to be a slight decline in the mortality rate in some areas. It is sad that the discovery of a lump in the breast brings such 388 SURGERY OF THE INTEGUMENTARY SYSTEM terror to many women that early diagnosis and treatment is de- layed. The fear of mutilation and death seems to underly their thoughts about cancer. Healthy women who have had radical mastectomies rarely tell anyone about them. The patients with lingering, hopeless conditions, where the tumor has caused ulcera- tion with subsequent foul odor and pain from metastatic lesions, are well known. Much has been done to educate the people in a positive way by stressing that women following radical mastectomy may lead an active life; limitation of activity need not follow the operation and a prosthetic appliance will allow clothes to fit as naturally as before operation. Whether the patient has been told that she almost certainly has a benign tumor or that she will probably have her breast removed the nurse may assume that she has been worried and concerned since the time the tumor was discovered. Apprehension, despair and resentment are usually not expressed because of the fear of rejection. Warmth, understanding and re- assurance are supportive needs which the nurse can give this pa- tient, especially at the time of admission. Treating her as a guest, making her Comfortable and giving her opportunities to ask ques- tions about anything she does not understand are essential to prevent further anxiety. Too often, the busy and impersonal en- vironment adds to the fears of the patient. Preoperatively, the patient should be shaved as shown in Fig- ure 30, page 72, and prepared for general anesthesia. When the tumor has been proved to be benign, a small dress- ing will be placed over the incision. Careful attention is given to the vital signs of the patient as after any surgery. The patient is usually discharged from the hospital the following day. She is given instructions to return to her surgeon for removal of the sutures, and to keep the dressing dry. Following radical mastectomy, general supportive care is in- dicated. In addition, elevation of the arm, on the operative side, on pillows provides comfort and helps prevent edema. Most sur- geons place a drain in a stab wound in the axilla to permit the escape of serum which accumulates beneath the extensive skin flaps. The dressings are usually large and tight in order to press the skin flaps tightly against the underlying thoracic wall until the healing process is well begun. The dressings should be in- spected frequently at the back of the axilla to detect bleeding or excessive drainage. Inspection, at least every fifteen minutes, should be made for the first few hours after operation. When ooz- SURGERY OF THE BREAST 389 ing occurs, the size and color of the stain should be noted; if it increases it should again be reported to the surgeon. Turning is difficult, and the position on the side opposite the wound is un- comfortable unless the shoulder, back and arm are supported by pillows. When a skin graft has been applied, the large pressure dressings will usually prevent it from slipping, but care must be taken that undue movement of the dressing be prevented until such time as circulation into the graft is well established. The skin graft is usually taken from the thigh; a tight bandage will be in place and is left undisturbed for about two weeks; after this interval, the area will be healed. The initial dressing of the breast area may be done on the fifth or sixth day at which time the drain is usually removed, together with the sutures. The day after operation the surgeon encourages the patient to use her arm. A convenient and simple scheme which insures early and satisfactory function is to persuade the patient to comb her hair. Patients who have had radical mastectomy may get out of bed the day after operation. Encouraging the patient to Cough and breathe deeply is essential to prevent chest complications. A diet as tolerated is usually ordered; the importance of adequate protein should be emphasized. During the convalescent period emotional support should be given. Nearly all patients become depressed although, in most, this is brief and mild. Frequently they sleep poorly because they have dreams concerned with mutilation and loss of bodily func- tion which frighten them. An attentive family is most essential to buoy up the spirits; if they can make the patient feel they love her and accept her she will adapt herself with greater ease. The nurse should encourage the family to show added attention since it is they who are most important in helping the patient to adapt to her former area of living. The nurse should also find out what the patient knows about prosthetic appliances. If she is unfamiliar with them, there should be samples available to show her. A strong interest on the part of the nurse will usually bring forth many questions. Sometimes the surgeon recommends the type of appliance to be used; if not, he should always be informed about the patient's questions, to permit him to clarify any answers providing guid- ance to the patient and nurse. It is best when the patient can decide what she wishes to do about this aspect. The nurse's best function is to inform her. The nurse should also find out what her patient knows about breast self-examination during 390 SURGERY OF THE INTEGUMENTARY SYSTEM Convalescent care; iſ she does not know, then she should be taught according to the plan of the surgeon, unless such practice is already accepted throughout the hospital. Beſore discharge, the nurse makes certain the patient knows when to return to the surgeon. SUMMARY Until better means become available, the early diagnosis of and the radical operation for cancer of the breast are the best treatment for this common disease of women. Education of the public and general use of regular self-examination have already improved the cure rate and can accomplish even more. Radiation and hormone therapy also have important uses. Many lumps in the breast are not cancer, but only examination of the tissue under the microscope can make diagnosis certain. VOCABULARY REVIEW polymastia galactocele mastectomy gynecomastia mastitis teSto.SterO776 SUGGESTED READING I. A Cancer Source Book for Nurses. New York, Am. Cancer Soc., Inc., 1950, pp. 59–63. 2. Cancer Nursing. National Cancer Institute and New York State Dept. of Health, 1950. 3. Current Status of Hormone Therapy of Advanced Mammary Cancer. Coun cil on Pharmacy and Chemistry. J.A.M.A. 146:471-476 (June 2) 1951. 4. Newton, Michael, and Newton, Niles Rumely: Breast Abscess, A Result of Lactation Failure. Surg, Gynec. & Obst., 91:651–655 (December) 1950. 5. Rusch, H., and Baumann, C.: Nutritional Aspects of Cancer Problems. Nutritional Review, 4:353, 1946. i 6. Smith, Genevieve W.; When a Breast Must Be Removed. Am. J. Nursing, 50:335-339 (June) 1950. 7. Sugarbaker, Everett D., and Wilſley, Lucy E.: Cancer of the Breast. Am. J. Nursing, 50:332–335 (June) 1950. 8. Self-Examination of the Breasts. Am. J. Nursing, 52:441 (April) 1952. Unit VII. DISEASES DUE TO ALLERGY CHAPTER 33 The Role of Surgery in Allergic Disease Allergy has been defined as a condition of unusual or exaggerated Specific susceptibility to a substance which is harmless in similar amounts for the majority of people." Hay fever, hives, and asthma are some of the more common manifestations of allergy. Other less Common allergic reactions include headache, circulatory col- lapse (anaphylaxis), gastrointestinal disturbances, and a variety of skin eruptions. No successful direct attack upon allergy has been made by surgery, nor is it likely that surgery will ever have a part in the direct treatment of this condition, since the allergic reaction seems to be a property of the cells of the body. Surgery is often useſul, however, in attacking the causative agent of the allergy (allergen). Thus, the eradication of chronic bacterial infection in the paranasal sinuses is beneficial in many cases of bronchial asthma. 1 See Brown, pages 619–637. 391 392 DISEASES DUE TO ALLERGY Anticipating Sensitivity. The surgeon, on the other hand, is often forced to deal with allergies in patients who have some other disease as well. There are persons who are hypersensitive to morphine, or to iodine, or to some other substance which the surgeon ordinarily uses in treating his patients. Again and again the value of careful history-taking is demonstrated, as the unto- ward effects of an allergy may usually be prevented if the surgeon is forewarned. Certain of the medicaments that a surgeon com- monly uses produce hypersensitivity, or cause severe allergic reac- tion in previously sensitized persons; tetanus antitoxin is one of these, its ill effect being due to the horse serum from which it is prepared; penicillin is another. Patients in whom these or similar substances are to be injected should first have a skin test to de- termine the degree of sensitivity so that proper precautions may be taken. Epinephrine must be readily available in case serious symptoms should develop. & It is indeed fortunate that cortisone has proven so beneficial in alleviating the manifestations of serious allergic reactions. Unit VIII. SURGERY OF THE ENDOCRINE GLANDS THE ENDOCRINE glands of the body are the pituitary, the thyroid, the parathyroids, the thymus, the islet tissue of the pancreas, the adrenals, and the gonads (the testes in males, the ovaries in females). The secretions (hormones) elaborated by these glands exert a powerful influence on every phase of the growth and ac- tivity of the individual, and there is a highly complicated inter- relationship between the different glands. Some of these glands elaborate more than one hormone, each having a different action upon the rest of the body. Much is now known concerning the chemical structure and the nature of the action of many hor- mones, but there is still a great deal to be learned, particularly as to the regulatory effect of certain of the hormones upon the pro- duction or action of other hormones. Surgery is employed in the treatment of diseases of endocrine origin, the so-called endocrinopathies, to remove overactive glands, wholly or in part, and to attempt Compensation for or replacement of deficient glands. As yet the transplantation of glandular tissue from another person or from an animal has not been satisfactory, but it has been found possible to achieve much success by the implantation of slowly absorbed pellets of the active chemical principles of the hormones of some glands. In addition to this direct application of surgery to endocrinopathies, the surgeon is frequently confronted by the occurrence of all the ordinary surgical problems in patients who have also an endo- crine derangement. Then, too, an endocrine derangement may be the accidental or resultant Complication of a surgical pro- cedure. 1 See Brown, pages 638–713. 393 CHAPTER 34 Surgery of the Thyroid and Parathyroid Glands THE THY ROID Anatomy and Physiology. The thyroid gland is a butterfly- shaped organ which lies in the lower part of the neck astride the trachea. There are two lateral lobes, one on each side of the trachea, which are connected by a narrow strip of thyroid tissue, the isthmus. The blood supply of the gland is rich. On the in- ferior surface of the thyroid lobes are the parathyroid glands, and between the inferior medial surface of the lateral lobe and the trachea on each side is located the important recurrent laryngeal nerve. Because this nerve supplies the muscles which control the vocal cords, injury to it interferes seriously with speech and proper respiration. Weakness or paralysis of the muscles permits the vocal cord to flap loosely in the lumen of the larynx. The thyroid is one of the endocrine or ductless glands, so called because they secrete directly into the circulating blood. The secretions of endocrine glands are known as hormones. The chemical structure of the thyroid hormone, thyroxin, is well known; one of its elements is iodine. Thyroxin has a regulating effect upon the metabolism of the body. An increase in the amount of thyroxin, whether caused by disease of the thyroid gland or by therapeutic administration of the hormone, results in a speed-up of metabolism; this produces a faster breakdown of the body tissues which results in the need for more food. If the thyroid gland produces less than the normal amount of thyroxin, there is a slowing down of metabolism, usually mani. fested by lack of energy, diminution of activity, and gain in weight. Basal Metabolism Test. It is important to be able to measure the rate of metabolism of the patient and a convenient test has, been devised. In order to obtain the energy necessary to carry on the activities of living, the cells of the body use up protein, fat, and carbohydrate. Much of this process of utilization consists in oxidation reactions which make use of the oxygen derived from 394 SURGERY OF THE THY ROID AND PARATHY ROID GLANDS 395 Digastric M. Levator Scapula M. z | Ž Carotid A. Longus capitis M. Ant. Scalenus M. /// Internal jugular V. f Med. Scalenus M. | Post. Scalenus M. /// g ſ/ſ/ſiſ Omohyoid M. % fjiž Sternoîhyroid M %* ñºſ." º Sternohyoid M}% ſº º º {{U {\\{ º § º ºšº & e-Y 1 cle º Menu brium Parathyroid glands FIGURE 103. Anatomy of neck, showing relationship of thyroid to the other important structures of the neck. Insert shows the posterior aspect of the gland and the usual location of the parathyroids. inspired air. The rate, therefore, at which metabolism proceeds can be estimated from the rate of oxygen consumption. The test is carried out by having the patient breathe for a period of time into a closed system containing a measured amount of oxygen; provision is also made in the apparatus for absorbing the exhaled carbon dioxide. The amount of oxygen consumed varies, natu- rally, with the activity of the patient during the test; for this rea- son an attempt is made to perform the test under standard con- ditions of minimal activity, so that the metabolism will be at the lowest rate which is normal for that patient, or basal. It has been 396 SURGERY OF THE ENDOCRINE GLANDS found practicable to make the test just after the patient awakens from a good night's rest, before permitting the eating of break- fast or any other physical activity. Since the actual amount of oxygen consumed will be greater in larger persons than in smaller, tables have been made which show the average Oxygen consumption under basal conditions of large numbers of individ- uals according to height and weight. If the patient being tested Consumes the same amount of oxygen as the average normal of his size, his basal metabolic rate (B.M.R.) is reported as 0; if he consumes more oxygen than the normal average the B.M.R. is reported plus, and if less, minus. Values from +10 to — 10 are considered within the range of normal variation and are not taken to be evidence of disease. Disturbances of the Thyroid THY ROID DEFICIENCY Myxedema. In adults, insufficient Secretion of thyroxin pro- duces a condition called adult myxedema. In childhood the Con- dition is known as juvenile myxedema. It may occur spontane- ously, or as a result of the removal of too much of the thyroid. Myxedema is characterized by increased deposition of fat and thickening of the subcutaneous tissue, most noticeable in the face. The voice becomes coarse. There is a loss of mental alert- ness and the patients seem dull. The B.M.R. is low, -15 or lower. The treatment of this condition is to make up the de- ficiency in thyroxin, which is done by giving small daily doses of thyroid extract. If the condition has not progressed too far, treat- ment brings about great improvement; therapy must be Con- tinued permanently, however. Crefinism. In infants a congenital deficiency of thyroid hor- mone causes Cretinism. Endemic Cretinism is common in en- demic goiter regions; the incidence of sporadic Cretinism is not known, although it is rare in North America. There is a perma- ment mental deficiency in these children which is not amenable to treatment with thyroid, and there is a characteristic appear- ance as a result of growth abnormalities in the formative years. In addition, the signs and symptoms of myxedema are present. GOITER The term goiter means an enlargement of the thyroid gland. There are several varieties of goiter. Colloid Goiter. This generalized enlargement of the entire SURGERY OF THE THY ROID AND PARATHY ROID GLANDS 397 gland usually occurs during adolescence and is more frequent in females than in males. It is the result of a deficiency of iodine in the diet, and in parts of the world where the amount of iodine in the drinking water and diet is insufficient, such as mountainous regions and the Great Lakes Basin, colloid goiter occurs with fre- quency. The metabolism is generally normal or slightly reduced. Prevention and Treatment. Fortunately these goiters can gen- erally be prevented by the addition of minute amounts of iodine to the diet, most conveniently carried out by the use of iodized table salt. The administration of iodine is seldom effective after the colloid goiter has developed, although sometimes a small dose of thyroid extract is helpful in reducing the size of the goiter. Surgical removal of the goiter is advisable for cosmetic reasons and because continued enlargement may cause pressure upon the trachea and esophagus, with resultant interference with breathing and Swallowing. Nodular Goiter. This condition is most prevalent in those geo- graphic regions where Colloid goiter is common. Irregular en- largement of part of the thyroid gland generally appears early in adult life, but may be first noticed at any age. The condition is usually progressive and the enlargement may become tremendous. Frequently the tumors compress the trachea and embarrass res- piration. The goiter sometimes extends down into the thorax; this extension can best be determined by an x-ray of the chest, which should be taken in all cases of goiter. Microscopic examina- tion of the glandular tissue shows areas of degeneration, hemor- rhage, and cyst formation, with a varying amount of chronic in- flammation or nonspecific thyroiditis. These goiters can be dis- tinguished from true adenoma of the thyroid. Treatment. The treatment is surgical removal, and this is the only method offering permanent relief. Hyperthyroidism occa- sionally occurs in association with nodular goiter; for this reason a basal metabolism test should always be made before undertak- ing operation. The treatment of nodular goiter with hyper- thyroidism is essentially the same as the treatment for exophthal- mic goiter. Exophthalmic Goiter. Also known as primary hyperthyroidism and Graves' disease, this is a serious systemic disturbance. The thyroid gland is enlarged, but less so than in the colloid and adenomatous types of goiter. The enlargement is generally sym- metrical, and in itself causes no symptoms. The fundamental manifestation of this disease is the production of an increased 398 SURGERY OF THE ENDOCRINE GLANDS § 'ANS § º =ss. Sº Fº } * R JS * SS *Š ‘s-tºmsº smsº Incision FIGURE 104. Exophthalmic goiter. Dotted line indicates location of incision for thyroidectomy. amount of the thyroid hormone, which results in a speeding up of metabolism. Microscopic examination of the thyroid tissue shows evidence of increased activity of the cells of the gland. This disease occurs more ſrequently in women, generally in early adult life, but it may occur in children or in older persons. Symptoms. Patients with hyperthyroidism complain of nervous ness, trembling, increased sweating, loss of weight, increased ap- petite, and easy fatigability. Often they or their relatives notice a prominence of the eyes. Palpitation of the heart is a frequent complaint. In the more severe cases there may be nausea, vomit- ing and diarrhea. Diagnosis. On examination the patients are found to be alert and highstrung; they are easily upset and are given to fits of anger or crying. There is evidence of considerable loss of weight. There is a pronounced trembling of the hands. The moderate diffuse enlargement of the gland is easily felt. One of the most striking signs of the disease is the exophthalmos or prominence of the eyes, which may be so great that the lids will not meet. In extreme cases of exophthalmos operative procedures upon the lids or the orbit may be necessary to save vision. Fortunately this is an un- Common complication, and the exophthalmos often regresses SURGERY OF THE THYROID AND PARATHYROID GLANDS 399 partially after the hyperthyroidism has been cured. The pulse rate is increased proportionally to the severity of the disease. The B.M.R. is always elevated and in extreme cases may be as high as +100; in moderately severe cases it ranges from +30 to +50. Treatment. Primary hyperthyroidism is a progressive disease which usually leads to heart failure and death if not treated. Since the disease is characterized by regressions and exacerbations a temporary improvement must not be regarded as evidence of a CUITC. There are several related drugs which may be used to control the manifestations of hyperthyroidism. The most widely used of these is propylthiouracil. The administration of this drug over a period of weeks or months will usually produce a complete re- mission of the disease. In fact, in a large proportion of patients, this method of treatment appears to bring about a permanent cure; since this drug has only been in use for a few years, it is not certain yet that the cures are actually permanent. Many patients, however, develop a relapse after discontinuing the drug, but it will again be effective when taken. In a very small number of pa- tients propylthiouracil is toxic to the bone marrow and results in leukopenia; obviously, it is not safe to use without regular ex- amination of the blood of each patient who is taking it. Although surgical removal of thyroid tissue has been considered during the past half century the proper treatment of exophthalmic goiter, there is now available this medical means of treating the condi- tion. It seems probable that, in the future, fewer patients with this disease will be operated upon. At present, surgical treatment is indicated for those patients who do not secure permanent re- mission after adequate medical therapy, for those who cannot tolerate the drug, for those who do not have adequate medical facilities at hand, and for those who prefer not to take the medicine. The administration of iodine has a beneficial but temporary effect upon hyperthyroidism. Prior to the introduction of propyl- thiouracil, this was the drug of choice in preparing the patient for surgery. At the present time both propylthiouracil and iodine are used in the preoperative preparation of the hyperthyroid patient. The patient is usually given propylthiouracil until the metabolism returns to approximately normal. Following this, iodine is given for a period of about ten days or two weeks. This brings about a marked decrease in the size of the thyroid gland, decreases the blood supply and thus makes the operation less 400 SURGERY OF THE ENDOCRINE GLANDS difficult. The preoperative treatment can usually be carried out on an ambulatory basis with the patient getting as much rest as possible. Whether or not the patient discontinues work during this period of treatment would depend on the severity of the dis. ease and the type of work that was being done. A mild sedative is often useful in the treatment of hyperthyroidism. The patient should stop smoking and should avoid the use of caffeine. Be- cause of the weight loss and the increased metabolism a diet of 4000 to 5000 calories, chiefly carbohydrates, should be given. The patient should be encouraged to take as much rest as possible. Following adequate preoperative preparation, surgical re- moval of most of the thyroid gland is performed; cure of hyper- thyroidism thus results from reduction in the amount of thyroxin which can be produced. Adenoma of the Thyroid. There is a rather Common tumor of the thyroid which is best called a fetal adenoma. This is not to be confused with nodular goiter. Fetal adenoma is a true tumor and is surrounded by a capsule which separates it from the re- mainder of the thyroid tissues. It presents as a small round nodule in the gland, which is easily palpable, and varies in size from that of a small marble to a golf ball or larger. These tumors are usu- ally solitary, but finding more than one is not rare. Fetal adenomas have a definite tendency to undergo malignant de- generation, and about 10 per cent will in time become cancerous. This is an additional reason for the immediate removal of a thyroid nodule. It is often impossible to distinguish a small nodule of a nodular goiter or a small cyst from a fetal adenoma; therefore it is recommended that all solitary nodules of the thyroid be removed as soon as discovered. Carcinoma of the Thyroid. Several types of carcinoma are seen in the thyroid gland, but sarcoma is rarely seen. In early car- cinoma of the thyroid, when the disease appears limited to one side of the neck, total removal of the thyroid on that side, to- gether with radical resection of the cervical lymph nodes and jugular vein of the same side, is the proper therapy. In instances of extensive malignant disease of the thyroid, cure cannot be ex- pected from surgery; radiation therapy offers the best hope of pal- liation. Thyroiditis. Because it results in firm enlargement of the gland, inflammation of the thyroid gland may be confused with car- cinoma or other goiters. There are two chief varieties of this condition, Hashimoto's and Riedel's struma, but nothing is SURGERY OF THE THY ROID AND PARATHY ROID GLANDS 401 known of their causes. Often pain, tenderness, and fever occur, serving to differentiate them from cancer. Although often op- erated upon because of the difficulty in ruling out cancer, there is no real indication for surgical therapy in thyroiditis. Radiation and antibiotic therapy are sometimes used, but usually the Con- dition runs its course uninfluenced by therapy. Thyroidectomy Inhalation anesthesia is employed by most surgeons but local anesthesia is preferred by some. A low curved incision is made on the anterior surface of the neck, the muscles are either retracted or divided, and the gland is exposed. Removal of the desired amount of gland is then carried out, care being taken to avoid injury to the recurrent laryngeal nerves, parathyroid glands, esophagus, trachea, and structures of the carotid sheath. COMPLICATIONS Hemorrhage. A dramatic and serious Complication of thyroid- ectomy is hemorrhage into the wound from one of the large thy- roid arteries, usually the superior thyroid artery. The blood compresses the trachea and thus obstructs respiration; this causes the patient to have difficulty in breathing and to become cya- notic. In such cases prompt action is necessary to save the life of the patient. The dressing should immediately be removed; if there is swelling beneath the wound, this is sufficient evidence of hemorrhage, and immediate release of the pressure beneath the wound is necessary. If no doctor is available the nurse should not hesitate to open the wound and allow escape of the blood. The amount of blood lost is not important compared to the need for restoring respiration. Following the reestablishment of breathing the patient is taken to the operating room for control of hemor- rhage and closure of the wound. Thyroid Crisis. Thyroid crisis or storm is another serious post- operative complication in which the patient undergoes alarming exacerbation of the symptoms of hyperthyroidism. There is a rapid pulse, often 160 to 180 per minute, respiration is rapid, and there is high temperature. The patient is flushed, easily upset, and highly nervous. Death may occur from heart failure; there- fore every effort must be made to support the patient's strength. Glucose is given intravenously along with high fluid intake. The patient is placed in an oxygen tent. Nervousness and overactivity 402 SURGERY OF THE ENDOCRINE GLANDS are controlled by large doses of morphine given at regular inter- vals. Quiet is essential and everything possible should be done to make the patient comfortable. Paralysis of the Vocal Cords. This follows injury to the recur- rent laryngeal nerve. The clinical signs are noisy, labored respira- tion, and hoarseness. If the nerve has been entirely divided this will be a permanent condition, but if the nerve has only been traumatized without division, the condition will usually disap- pear after a few days. Following injury to both nerves there is loss of phonation and serious obstruction to respiration, which must be first treated with the administration of oxygen or of a combination of oxygen and helium; if this is not completely effective, tracheotomy is necessary as a life-saving measure. Parathyroid Function. Removal of some or all four of the para- thyroids will result in parathyroid insufficiency. If all four of the glands have been removed the condition will be permanent, but if one or more glands remain they will become hypertrophied and function will be restored to normal. This subject will be discussed further under parathyroid glands. NURSING CARE Posfoperative Care. When the patient returns from the oper- ating room, morphine is usually given to prevent restlessness. Special care is taken to prevent the aspiration of secretions. It is convenient to have an electric suction apparatus at the bedside to remove the excess saliva and mucus. As soon as possible the patient is placed in semi-Fowler's position in which he will feel more comfortable and will breathe more easily. The breathing and the color of the patient are watched closely so that difficult respirations and cyanosis may be instantly detected. An emer- gency tracheotomy set must always be kept ready for use in the ward. Increase in restlessness or in the pulse rate, or elevation of temperature must be reported to the surgeon. These are symp- toms of a crisis. In addition, muscular twitching or spasm of the hands and feet should be reported so that calcium or para- thyroid extract may be administered to relieve tetany. Fluids are usually given intravenously until the intake by mouth is sufficient. Fluids by mouth may be given in large amounts as soon as nausea Ceases. Coffee and tea are omitted to prevent overstimulation. The diet should be high in calories, and solid food given on the second postoperative day. º SURGERY OF THE THYROID AND PARATHYROID GLANDS 403 Many surgeons order oxygen in high concentration so that oxygenation of the blood can be accomplished with a minimum of effort on the part of the patient. The administration of oxygen is usually discontinued on the second day after operation. It is desirable that the same nurse care for the patient before and after operation. Unremitting effort is made to prevent ex- citement, worry, mental fatigue, physical discomfort, and over- eXertIOIl. It is helpful to the patient and his family if they are made to realize that the patient's health will not be restored at once but will continue to improve for several months after discharge from the hospital. Rcidioiodine A by-product of the development of the atom bomb has been the production of many radioactive isotopes of common elements. Since the thyroid gland utilizes iodine in manufacturing thy- roxin, it was logical to use radioactive iodine in studying and treating diseases of the thyroid. While radioiodine has not proven of much use in the treatment of thyroid cancer, it is definitely effective in hyperthyroidism. In many ways it would seem to be nearly ideal treatment for this condition. It is color- less and tasteless when dissolved in water, and usually only a single dose is needed. After treatment, there is a gradual return to health over a period of six to twelve weeks. If the late results are as good as preliminary results appear to be, it is probable that most patients with exophthalmic goiter will be treated in this manner in the future. Much use is being made of radioiodine as a diagnostic tool, since a good deal can be learned about thyroid function by studying the uptake of iodine by the gland. After administering a measured amount of radioiodine, Counts are taken over the gland with a Geiger Counter, and the uptake calculated. THE PARATHYROIDS Anatomy and Physiology. The parathyroid glands are gen- erally four in number. They are tiny bean-shaped organs of a brownish color which are situated beneath the lateral lobes of the thyroid, two on each side. There is considerable variation in their size and distribution, but the average size is about 2 millimeters. The parathyroid glands secrete a hormone which has 404 SURGERY OF THE ENDOCRINE GLANDS a powerful effect upon the metabolism of calcium and phos. phorus in the body and serves to stabilize the levels of calcium and phosphorus in the blood. Disturbances of the Parathyroids Hypoparathyroidism. Decreased function of the parathyroids is usually the result of their partial or total removal during op- erations upon the thyroid. This complication is more common in women than in men; why the female is predisposed is not known. Symptoms. Hypoparathyroidism is accompanied by a decrease in the level of the calcium and an increase in the level of the phosphorus in the circulating blood. This alteration in the chemical constitution of the blood, if extensive, results clinically in tetany, a condition in which there are severe muscle spasms and even convulsions. In severe cases death may occur unless the proper treatment is begun; in the less severe cases the signs and symptoms are less striking. These patients complain of Cramps in the peripheral muscles and tingling of hands and feet, and they may have spontaneous Carpal spasm. Diagnosis. There is irritability of the peripheral nerves which can be demonstrated by tapping with the finger on the cheek just in front of the external auditory meatus; this stimulates the facial nerve which causes contraction of the facial muscles (Chvostek's sign). In the normal person there is no response. Another test is to apply an ordinary blood pressure cuff to the arm and inflate it to above arterial pressure. Within two or three minutes the fingers will stiffen into a typical deformity known as “ob- stetrician's hand” (Trousseau's sign). Treatment. Hypoparathyroidism can be successfully treated by injections of parathyroid extract, either alone or in conjunction with the administration of calcium. Calcium gluconate should be given intravenously for immediate relief of tetany, and daily doses of calcium chloride may be taken by mouth to maintain an adequate calcium level. In cases in which removal has been incomplete, hypertrophy of the remaining parathyroid tissue occurs and treatment is gradually discontinued. Hyperparathyroidism. Increase in parathyroid function is usu- ally caused by an adenoma of one of the glands, and is accom- panied by an increase in the calcium and a decrease in the phos- phorus in the blood. This results in removal of calcium from the SURGERY OF THE THY ROID AND PARATHY ROID GLANDS 405 ~2% º gº § sº sº § s\\\ FIGURE 105. Carpal spasm (obstetrician's hand). bones and an increase in the amount of calcium and phosphorus excreted in the urine. Symptoms. In severe cases these patients complain of intense pain in the long bones. X-ray examination shows decalcification of the bones with cyst formation. Kidney stones are also a fre- quent complication as a result of the excess excretion of cal- cium in the urine. Hyperparathyroidism should be suspected in any patient who shows a tendency to form renal calculi. Treatment. Treatment consists in the surgical removal of the parathyroid adenoma. This may be located at the site of any of the normal glands or may arise from aberrant parathyroid tissue elsewhere in the neck or mediastinum. These tumors are not usually large enough to be palpable or to cause any symptoms referable to their size and are often hard to find at operation. Good results may be expected following the removal of an adenoma. The disappearance of pain in the bones is often dra- matic, occurring within a few hours. Postoperative Nursing Care. After operation these patients may temporarily develop tetany. The calcium and phosphorus levels in the blood should be followed carefully and the nurse should be alert for any signs of developing tetany. SUMMARY There are several varieties of goiter, and the chief reasons for surgical removal are mechanical, Cosmetic, and prevention of cancer. Although the treatment of exophthalmic goiter has been one of the brilliant surgical successes of this country, it now seems 406 SURGERY OF THE ENDOCRINE GLANDS probable that most patients with this disease will be treated by drugs or radioiodine. VOCABULARY REVIEW parathyroid isotope propylthiouracil thyroxin myxedema goiter tetany cretin SUGGESTED READING 1. Cerise, Elmo J., Spears, Randall, and Ochsner, Alton: Carcinoma of the Thyroid and Nontoxic Nodular Goiter. Surg., 31:552–561 (April) 1952. 2. Crile, George, Jr.; Treatment of Hyperthyroidism—An Editorial. Surg., Gynec. & Obst., 91:242-244 (Aug.) 1950. 3. Christopher, Frederick: A Textbook of Surgery. 5th Ed. Philadelphia, W. B. Saunders Co., 1949, pp. 610–613. 4. Hawley, E., and Garden, G.: The Endocrines and Their Role in Nutrition. 3rd Ed. St. Louis, C. V. Mosby Co., 1949, pp. 111-119. 5. Hinton, J. W., and Lord, J. W., Jr.: Is Surgery Indicated in All Cases of Nodular Goiter, Toxic or Nontoxic? J.A.M.A., 129:605-606 (October 27) 1945. 6. Lahey, Frank H., and Hoover, Walter B.: Tracheotomy after Thyroidectomy Ann Surg., 133:65–76 (January) 1951. 7. McLester, James S.: Nutrition and Diet in Health and Disease. Philadelphia, W. B. Saunders Co., 1950, pp. 668–671. CHAPTER 35 Surgery of the Pituitary, Thymus, Pancreas, and Adrenals THE PITUITARY This gland, also called the hypophysis, is composed of three parts, the anterior lobe, the pars intermedia, and the posterior lobe. It is located within the cranial cavity, immediately beneath the midbrain and behind the intersection of the optic nerves (optic chiasm). Although the pituitary secretions, especially that of the anterior lobe, appear to be the all-important pacemakers of all endocrine activity, surgical interest centers chiefly on tumors of the gland. Pituitary tumors often cause endocrinopathy, but the main reason for treating them surgically is to relieve SURGERY OF PITUITARY, THYMUS, PANCREAS 407 the mechanical pressure caused by them upon the adjacent optic nerves and midbrain. The diagnosis and operative removal of pituitary tumors fall properly within the sphere of the neurosurgeon, and are dis- cussed in the unit on surgery of the central nervous system (p. 423). THE THYMUS Situated in the chest between the sternum and the anterior sur- face of the great vessels and the heart, this gland is large in in- fancy and tends to disappear later in life. Little is known of its function or secretion. There appears to be a relationship between the activity of the thymus and a serious disease called myasthenia gravis, in which the muscles of the body tire easily. Some patients suffering from this disease have benefited by the surgical re- moval of the thymus. THE PANCREAS The endocrine portion of the pancreas, the islet tissue, secretes insulin, a hormone which is necessary for the proper utilization of carbohydrates in the metabolic processes of the body. Diabetes. Insulin deficiency produces the clinical disease known as diabetes. The problem of the surgical patient who has diabetes is one which demands the closest cooperation between physician and surgeon. In general it may be said that the sur- gical problems are subordinate to the regulation of the patient's carbohydrate metabolism; once this is controlled, with con- tinuous regulation planned, the patient may be treated like any other surgical patient." Modern knowledge of diet, together with insulin and intravenous therapy, has greatly reduced the hazard of surgery for patients with diabetes. Adenoma. A serious but fortunately uncommon disease, ex- actly the reverse of diabetes, is produced by a tumor (adenoma) of the islet tissue of the pancreas. The islet adenoma, by se- Creting excessive amounts of insulin, causes serious reduction in the amount of sugar in the blood (hypoglycemia), resulting in shock with or without convulsions, which may terminate fatally. Patients suffering from this condition learn to carry sugar or candy in their pockets, and to eat some when the symptom of faintness appears; this, of course, elevates the sugar level in the blood and temporarily prevents loss of consciousness or con- 1 See Brown, pages 650–694. 408 SURGERY OF THE ENDOCRINE GLANDS vulsions. Suspicion of this disease warrants surgical exploration of the pancreas, for if the adenoma, often tiny, can be found and removed, a cure will result. Nursing Care. Before operation such a patient is usually or- dered additional food between meals, especially at night, to pre- vent weakness and convulsions. Usually, for diagnostic purposes, it is necessary for the patient to fast. Whenever this is done, it is advisable to ask the surgeon whether or not the patient should have bedside candy or orange juice. Often, during the fasting stage, it is necessary for the nurse to remain at the bedside to prevent the patient from injuring himself. These patients have been mistakenly considered to be mentally ill because of their bizarre behavior during hyperinsulinism. They need assurance of protection and help from the nurse, to make them feel as secure as possible. After operation, the care given to a patient with resection of the pancreas may be applied. Tact, patience and kindness are required to help this patient overcome the feelings of inferiority he may have because of his insulin reactions. THE ADRENALS This pair of glands, also known as suprarenals from their loca- tion just at the upper pole of each kidney, secretes hormones which are essential to life, and which affect the regulation of so- dium and potassium balance in the blood, carbohydrate metabo- lism, the activity of smooth muscle, the blood pressure, and the activity of the other endocrines, notably the gonads. Among the better known of the adrenal hormone substances are epinephrine (Adrenalin), nor-epinephrine (Levophed), cortisone and des: oxycorticosterone (DOCA). Benign Tumors. Benign tumors of the adrenal are of interest because, although of infrequent occurrence, they may produce large amounts of one or another of the adrenal hormones, with characteristic symptoms and signs. One variety of tumor causes sexual precocity in infants, or may cause virilizing effects in fe- males. Another type, the pheochromocytoma, secretes adrenalin; the patient presents the evidence of hypertension, usually in acute Crises. Carcinomas. Malignant neoplasms of the adrenals also occur; these are less likely to produce endocrine disturbance but are more difficult to cure as they are extremely invasive, metastasiz ing early and without symptoms. SURGERY OF PITUITARY, THYMUS, PANCREAS 409 Addison's Disease. This grave and formerly fatal disease is due to adrenal insufficiency.” Symptoms and Diagnosis. Low blood pressure, progressive weakness, and a curious bronze pigmentation of the skin are indicative. It is characteristic for the pigmentation to appear in the mucous membrane of the mouth. There are associated de- rangements of the blood chemistry, notably in the sodium and potassium balance. Treatment. There is no direct surgical attack possible upon this disease, but substitution therapy has proved life-saving. Pel- lets of desoxycorticosterone, the active chemical principle of the adrenal Cortical hormone, are implanted in the subcutaneous tis- sue of the back; absorption of the chemical is slow and takes place at the rate needed by the body. It is necessary to implant additional pellets at regular intervals, usually six months or longer, to control the adrenal insufficiency and maintain a nor- mal life. Patients with Addison's disease are especially susceptible to respiratory infections. It is always advisable for the nurse to wear a mask; even a mild cold is dangerous. The nurse should also be aware of the patient's great sensitivity to all opiates. No opiates are ordered preoperatively or after operation. More than usual tact and forbearance are called for as these patients are often irritable and difficult to handle. A special diet is used which is high in calories (5000 to 6000). SUMMARY Benign tumors of the pituitary, pancreas, and adrenal may produce abnormal amounts of the various hormones, resulting in serious effects upon the individual. Removal of such tumors results in cure. VOCABULARY REVIEW hypophysis hypoglycemia desoxycorticosterone pituitary hyperinsulinism cortisone thymus pheochromocytoma SUGGESTED READING 1. Blalock, Alfred: Tumors of the Thymic Region and Myasthenia Gravis: Am. J. Surg., 54:149-150 (October) 1941. 2. Clagett, O. Theron: Myasthenia Gravis, Medical and Surgical Treatment. Am. J. Nursing, 51:654–655 (November) 1951. 2 See Brown, pages 696–712. 410 SURGERY OF THE ENDOCRINE GLANDS 3. Greiling, Gladys E.: Myasthenia Gravis, Nursing Care. Am. J. Nursing, 51: 655–657 (November) 1951. 4. Krause, Marie V.: Nutrition and Diet Therapy. Philadelphia, W. B. Saun- ders Co., 1950, pp. 239–298. 5. Priestley, J. T., Comfort, M. W., and Sprague, R. G.: Total Pancreatectomy for Hyperinsulinism. Due to Islet-Cell Adenoma: Follow-up Report 5% Years After Operation, Including Metabolic Studies. Ann Surg., 130: 211–217 (August) 1949. 6. Thorn, G. W., Howard, R. P., Emerson, K., Jr., and Firor, W. M.: Treat- ment of Addison's Disease with Pellets of Crystalline Adrenal Cortical Hor- mone (Synthetic Desoxycorticosterone Acetate) Implanted Subcutaneously. Bull. Johns Hopkins Hospital, 64:339 (May) 1939 Unif IX. NURSING IN NEUROLOGIC SURGERY CHAPTER 36 Introduction Anatomy and Physiology. The brain is a soft, semifluid organ, housed in a rigid case, the bony skull. In the base of the skull there are numerous small openings (foramina) for the passage of the Cranial nerves and vessels, and one large opening (foramen magnum) for the spinal cord. The skull and the spinal canal are lined with a tough fibrous membrane (dura mater). The brain and the spinal cord are covered directly with a filmy mem- brane (pia-arachnoid) in which are blood vessels and the areas (subaranchnoid spaces) containing the cerebrospinal fluid, which is a clear fluid elaborated by clusters of blood vessels (choroid plexuses) which are situated in the cavities (ventricles) of the brain. The elaboration of the fluid is mainly—if not entirely— a process of filtration from the blood stream. Within the brain there are four main cavities, constituting the ventricular system. One of these, the lateral ventricle, lies in each cerebral hemisphere and communicates with the third ven- tricle, which is situated in the midbrain, by means of the foramen 411 4 12 NURSING IN NEUROLOGIC SURGERY Left and right foramen of Monroºrºº: .*- : * * e * * * & g * e 8 * * * * * * Ş..." s.r.º. }} § 2 º,39; º \\ º: º * tºº n º § % § - : . . . .''... * * " . . . . . . . . Mºno, ‘. . . . . . . . . Cisterna chiasmatis Cisterna interpeduncularis Descending horn of lateral ventricle Cisterna pontis Aqueduct of Sylvius Right and left foramen of Luschka Foramen of Magendie Cisterna magna ... (cerebellomedullaris) FIGURE 106. The ventricles of the brain, and the circulation of the cerebro spinal fluid (courtesy of Walter E. Dandy, Jr.). of Monro. A small channel, known as the aqueduct of Sylvius, connects the third ventricle with the fourth ventricle, which is located between the medulla and the cerebellum. The spinal fluid escapes from the fourth ventricle through the openings of Luschka and Magendie into the subarachnoid spaces where it is eventually absorbed. The arrangement of nerve cells and nerve pathways in the brain is extremely complex. Certain general features, however, must be kept constantly in mind. In general, nervous impulses from the right cerebral hemisphere are directed to the left half of the body, and those from the left hemisphere to the right half of the body. Furthermore, there is a regular representation upon the brain surface (cerebral cortex) of each body area: for exam ple, a small area of the left cerebral cortex near the top of the INTRODUCTION 4 || 3 Cent, sulcps (Rolando) Precent. gyr. V (motor) - ~~~" Postcent. gyn .* *. (sensory) / \ ^ P3 ^{\ #2 2x2 > * X. Ż % f 7 2. ' 6.4 ©y à 92% & £ §|N||... ? |i, #|| S., ; Š ſ| Y R. k | • * * * QS rº 3. l Sºº C l P. TN. S$ ºffi!! N lºbº /* 227 \\ sº º FIGURE 107. Schematic illustration of the representation of the regions of the body upon the cerebral cortex. Lat. fissure (5ylvius) CNE * * *~ head controls the movements of the right leg. One of the most im- portant of the cerebral areas is a portion of the left temporal region known as the speech center. This is unpaired, there being only one speech center, always on the left side in a right-handed person. The centers of control of automatic activity, including respiration, circulation, and metabolism, lie deeper in the mid- brain and the medulla. There are twelve pairs of nerves arising from the brain itself; these are the Cranial nerves. In addition to supplying impulses for ordinary sensation from the head and the motor control of the head, the cranial nerves furnish pathways for the important special senses of smell, vision, taste, equili- brium, and hearing. The spinal cord and spinal nerves serve as pathways for impulses between the brain and the rest of the body below the head. The brain is well supplied with blood vessels, as befits so spe- cialized and active an organ. Brain cells are delicate and die quickly (in seven minutes or less) if deprived of blood supply or Oxygen. This fact is important, because (1) the many small ar- teries are terminal arteries, without anastomoses, and occlusion 414 NURSING IN NEUROLOGIC SURGERY of them means loss of circulation to the area supplied by the artery; and (2) anoxia from any cause may result in the death of a part or all of the brain. Another characteristic of the Central nervous system is the inability of this tissue to heal with restora- tion of function. Following injury there is loss of tissue and scar formation, but no repair of the injured or destroyed nervous cells. Loss of function due to loss of brain tissue is permanent. This is equally true of the spinal cord, and of those portions of the cranial and spinal nerves which lie inside of the skull and spinal Canal. CHAPTER 37 Infracranial Injuries Automobile accidents, athletics, and accidental falls combine to make intracranial injuries common. The brain is well protected by its bony armor, but a blow upon the head is often of sufficient force to damage the nervous tissue, tear small blood vessels, or even fracture the skull, sometimes severely lacerating the brain itself. A violent blow upon one side of the head may cause dam- age to the brain opposite the side struck (contrecoup), just as an orange thrown forcibly against a wall may burst open on the side opposite to that striking the wall. Although bony fragments may be driven inward (as in depressed fracture) with consequent trauma to the underlying brain, severe damage to the brain some- times results without any disturbance of the continuity of the skull. The seriousness of an injury to the head depends not upon the fracture of the skull, but upon the amount of damage to the brain. Following violence there are hemorrhage if the vessels have been torn, and swelling (edema) due to outpouring of tis- sue fluid if the brain tissue has been damaged. This resulting increase in Cranial Contents causes an increase in intracranial pressure. The surgeon, in treating a head injury, has therefore three problems to consider: (1) the local injury to scalp and skull; (2) the damage to the brain; (3) increased intracranial pressure. Of these three, the last is the most important considera- tion, since little can be done to repair actual damage to the brain. INTRACRANIAL INJURIES 415 RESULTS OF INTRACRANHAL INJURIES Increased Infracranial Pressure. There is some variation in the intracranial pressure of normal persons, but it is usually between 120 and 180 mm. of water, as measured by a manometer Con- nected to a needle introduced into either the spinal canal or the lateral ventricle. Signs and Symptoms. Following an increase in the cranial Con- tents, whether due to fluid (edema), hemorrhage, tumor, or other cause, symptoms and signs develop which are due to Com- pression of the less resistant portions of the brain tissue. The brain is able to withstand gradual slow compression far better, and for a longer time, than sudden rapid increase in intracranial pressure, but a sufficient degree of either will cause irreparable and often fatal damage. SUDDEN INCREASE. The constant and most reliable sign of Sud- den change in intracranial pressure is the state of consciousness of the patient. A perfectly conscious person responds well to questions, is oriented with respect to time and place, and ap- pears alert. Unnatural drowsiness and disorientation may indi- cate the onset of increased pressure; wild delirium or restlessness alternating with periods of quiet may indicate the onset of coma; the completely unconscious person responds to no stimulus, breathes stertorously, and is incontinent. This sequence of events may occur with great rapidity; often it is absent when a person is rendered immediately and completely unconscious by a severe Injury. Recovery from coma presents exactly the reverse order of events. Restlessness may presage a return of consciousness; disori- entation and drowsiness disappear as recovery is complete. There- fore, when a patient is observed to be restless it is extremely im- portant to know whether he has previously been unconscious or conscious, since the restlessness may indicate either beginning recovery or progressive compression of the brain. Other indices of acute increase in intracranial pressure are, in the order of their reliability: (1) rapid progressive elevation of body temperature, which may rise a degree or more every hour; (2) slowing of respiration (bradypnea); (3) slowing of pulse rate (bradycardia); (4) elevation of blood pressure. In any given patient all or none of these signs may be present, since there is the widest variation in individuals. The change in body tempera- ture is almost as reliable a sign as the state of consciousness; the other signs are far less reliable. 4 16 NURSING IN NEUROLOGIC SURGERY GRADUAL INCREASE. Where the increase in intracranial pressure takes place over a period of many days or weeks rather than a few hours, there is a different sequence of events. Headache, diz. ziness, vomiting, and visual disturbance occur. Weakness or paralysis of the various cranial nerves due to continued pressure present characteristic signs. An important indication of gradual increase in intracranial pressure is papilledema (choked disk), which is swelling of the retinal end of the optic nerve, visible through the pupil of the eye by means of an ophthalmoscope. Retinal hemorrhages may also occur. Finally, with persistent increase in pressure the changes described in acute compression take place. Bradycardia, disorientation, and drowsiness are fol- lowed by coma and incontinence, and by death unless the Com- pression is relieved. When the patient can no longer compensate for the slow increase in pressure the picture may become that of acute compression with startling rapidity. Convulsions. Convulsions are probably not caused by increased intracranial pressure, but the two conditions are frequently asso- ciated since many lesions produce both. A convulsion is a vivid and terrifying demonstration of the control which the brain ex- erts over the body. It may be defined as an involuntary and un- inhibited muscular contraction which affects a part or all of the body musculature and which results from an explosive discharge of nervous stimuli from the brain. A convulsion is always a sign of brain abnormality. Children have a ſar lower convulsive threshold than adults and frequently show convulsive phenomena following minor head injuries or in toxic states. Therefore a convulsion in a child is not so indicative of severe brain abnormality as it is in an adult. Tumors, inſections, traumatic injuries, various drugs and noxious chemicals, certain alterations of the metabolic environ- ment such as anoxemia or hypoglycemia, and congenital abnor- malities—in a word, any condition which causes damage to the nervous cells of the cerebral hemispheres may produce convul- sions. In addition, convulsions occur in the absence of any demonstrable cortical lesion (as in so-called idiopathic epilepsy). Varieties. Convulsions are of two types: clonic and tonic. The tonic type, which produces tetanic spasm of muscle, is uncom- mon. The first or clonic type is the common variety, and is char- acterized by intermittent muscular contraction. Clonic convul- sions are often known as epileptiform since they occur in epi- lepsy. Convulsions may be localized, involving only a portion of INTRACRANIAL INJURIES 4.17 tº a 9.3\%. , fº $º.* * * FIGURE 108. Subdural hematoma. The blood clot is compressing the brain. the body, or they may be generalized. At times a severe seizure may begin with localized convulsions which develop into gener- alized convulsions. This phenomenon, iſ properly observed, will provide information that is useful in designating the portion of brain affected. Clonic convulsions are thought to result from stimuli arising in the cerebral hemispheres, whereas tonic con- vulsions result from stimuli originating in the brain stem. Concussion. Every one speaks of Concussion but no one really knows what happens to the brain in this condition. A blow or violence to the head is followed by brief loss of consciousness, then by recovery accompanied by headache, dizziness, vomiting, or brief disorientation. These symptoms may be absent or only transitory. After an interval the patient's recovery is complete. Obviously this is a mild form of head injury, and the treatment is that described on page 418. Extradural Hemorrhage. Occasionally the middle meningeal artery is torn at the point where, leaving the skull, it enters the Cranial cavity. This injury produces arterial bleeding between bone and dura, which results in rapid compression of the brain. The initial symptoms and signs are slight, but after a brief inter- val rapidly progressing signs appear which indicate compression 4.18 NURSING IN NEUROLOGIC SURGERY of the brain. These signs often point to compression of one cere- bral hemisphere. This condition demands prompt recognition in order that operative procedures designed to stop the bleeding and evacuate the blood (hematoma) may be undertaken in time. Acute Subdural Hematoma (see also p. 436). One of the cere- bral veins or dural sinuses may be torn with resultant bleeding into the subdural space. The signs are those of cerebral Com- pression which, however, is much less rapid than in extradural hemorrhage where the bleeding is arterial. There is usually severe concomitant damage to the brain. Hydroma. A similar picture is seen in subdural hydromas where a tear in the arachnoid permits escape of cerebrospinal ſluid into the subdural space. These hydromas are much more frequent in children than in adults. TREATMENT OF INTRACRANIAL INJURIES Any person receiving a ſorceful injury to the head may suffer intracranial damage. The degree of violence need not be suffi- cient to produce immediate unconsciousness; on the other hand, loss of consciousness due to a blow upon the head should be taken as certain evidence of intracranial injury. About four fifths of the persons so injured recover with no treatment other than measures designed to protect and sustain them while uncon- scious. About one tenth will be so severely injured that death is inevitable. When the brain is severely damaged the patient will usually die within four hours more or less. Experience has shown that there is no form of treatment or operative procedure which can save these lives. The remaining small fraction of the whole group represents borderline cases where proper treatment may save life. Skin wounds are dressed but not sutured, hemorrhage is checked, and fractures of long bones are splinted if necessary. Shock is treated (p. 68) but in applying heat the possibility of burning an unconscious patient must be borne in mind. Trans- fusions and intravenous ſluids are withheld unless absolutely necessary, as it is not desirable to elevate the blood pressure in the ſace of possible intracranial bleeding. Nothing is permitted by mouth, to avoid aspiration of fluid. X-ray Examination. It is unnecessary at this time to subject the patient to x-ray examination of the skull, as the treatment depends upon the damage to the brain, and not upon the condi- tion of the skull. When it is suspected that a fragment of skull INTRACRANIAL INJURIES 419 is depressed into the brain, roentgenograms should be made at the end of the observation period, if the patient's condition per- mits. Spinal Puncture. Spinal puncture as a diagnostic or therapeutic procedure is the subject of an active controversy. Some authori- ties hold that it is dangerous and unnecessary; others consider it safe and useful. It is significant to note, however, that the results of treatment of head injuries by spinal puncture are not better than the results of treatment without that procedure. General Measures. The patient is kept quietly in a bed with sides, and care is taken to prevent further damage from con- vulsive or delirious movements, from inadequate airway, or from aspiration of mucus and vomitus. Convulsions. Since Convulsions are a symptom of brain abnor- mality, treatment must be aimed at the correction of that ab- normality. Important information as to the location of the brain abnormality may sometimes be derived from accurate observa- tion of a convulsive seizure. The portion of the body first in- volved, the order of spread to other regions, the degree and duration of unconsciousness, and weakness or paralysis afterward should be noted. During convulsions the patient must be protected from injury, such as falls, burns, biting the tongue, and aspiration. Firmly attached sides on the bed prevent the patient from falling out of bed. The insertion of a padded mouth gag between the upper and lower molars prevents biting of the tongue. When the con- vulsion is prolonged, turning the patient on the side and lower- ing the head facilitates drainage of mucus from the throat. Ex- cess mucus may be removed by suction. Iſ convulsions are ſre- quent in occurrence, or are constant (status epilepticus), meas. ures must be undertaken to control them lest the patient die of exhaustion. Large doses of sedatives, or even general anesthesia, may be necessary. Observation Period. At the outset, careful and gentle exam- ination of the patient is made, including a thorough survey to ascertain the extent of other injuries and to determine the neu- rologic status. This examination is repeated at intervals, to de- tect changing or new signs. The degree of intracranial injury, upon which treatment is to be based, may be estimated only by observing the patient for several hours. During this observation period a careful record is kept of the state of consciousness, movements of body (including 420 NURSING IN NEUROLOGIC SURGERY eyes), convulsions, rectal temperature, pulse, respiration, and blood pressure. Scalp wounds are closed at the end of the observa- tion period. Nursing Care. Nearly all those patients who show evidence of improvement during the observation period will recover with conservative treatment, consisting of rest in bed, protection from harm during unconsciousness, maintenance of water balance, and proper care of wounds and other injuries. Restlessness is at times so great that restraint of the extremities is necessary to prevent the patient from harming himself. When restraints are used, both of the arm restraints should be fastened on the side of the bed toward which the patient is turned. Pneumonia is best prevented by a frequent change of the patient's position. Bleeding from the ear should be reported to the surgeon. The blood comes directly from the intracranial chamber through the inner and middle ear and runs out through the ruptured ear drum. No local treatment is carried out; the nurse should let it alone. There may be bleeding from the nose (epistaxis), and sometimes clear cerebrospinal fluid issues through the nostrils (rhinorrhea). The patient should be advised not to blow his nose because this may force infection into the brain. A chemothera- peutic agent is usually administered to combat or prevent infec- tl Oil. After-effects. While recovery is taking place the patient often appears to be fully conscious, talking, eating, and performing other routine acts, but memory and other higher mental func. tions may still be disturbed. Convulsions, complaints of headache and dizziness, and other symptoms sometimes appear months after apparent recovery from injury to the brain. It is often very difficult to determine whether the symptoms constitute a real after-effect of the injury, or whether the symptoms are induced by the thought of possible monetary compensation. Both are possible. Surgical Tredfmen? Of the remaining patients who have survived the observation period without improvement, some may be saved by adequate treatment. Small exploratory openings in the skull (trephinings) can be made without jeopardizing the patient's safety, and these may disclose beneath the skull fluid or blood which can be re- moved; if there is only diffuse edema of the brain, some room for expansion may be afforded by removing a portion of the skull INTRACRANIAL INJURIES 421 (decompression). Efforts to relieve edema of the brain by dehy- dration are generally unsatisfactory and at best give only tempo- rary relieſ. Depressed fractures of the skull should be elevated, or the bony fragments removed. EPILEPSY Epileptiform convulsions may be caused by many different types of brain abnormality (p. 416). The most notable advances In the study and classification of epilepsy have been made by measuring the minute electrical changes taking place across the surface of the brain (electroencephalography). Persons who have convulsions in the absence of any demon- strable pathologic lesions are considered to have idiopathic epi- lepsy, which is the same thing as saying that they have convul- sions of unknown origin. As yet no cure has been devised for this condition, which is indeed common, but the frequency of attacks may be lessened by the continued use of certain drugs, notably barbiturates and Dilantin, together with Careful observance of hygienic living. Epilepsy which is due to congenital deformities or to cerebral scars resulting from chemical or mechanical injury to the brain, is sometimes cured by the removal of the abnormal area. Unfor- tunately, the results of this procedure are by no means certain— in fact, epilepsy sometimes follows a cranial operation as a result of the trauma caused by the procedure. SUMMARY Accidental injury to the head and its contents is common. The most important index of the degree of injury is the state of con- sciousness. The nurse must be familiar with the signs of increas- ing intracranial pressure so that treatment may be undertaken before death or permanent damage to the brain occur. VOCABULARY REVIEW contrecoup epileptiform rhinorrhea bradycardia concussion decompression papilledema subdural otorrhea SUGGESTED READING 1. Carini, Esta, and Robinson, Franklin: Acute Cranio-cerebral Injuries. Am. J. Nursing, 50:423–427 (July) 1950. 2. Christopher, Frederick: A Textbook of Surgery, 5th Ed. Philadelphia, W. B. Saunders Co., 1949, pp. 446-466. 422 NURSING IN NEUROLOGIC SURGERY 3. Everts, William and Woodhall, Barnes: The Management of Head and Spinal Cord Injuries in the Army. J.A.M.A., 126:145–148 (Sept. 16), 1944. 4. Haynes, Walter G., and McGuire, Mary: Neurosurgical Nursing. Phila delphia, W. B. Saunders Co., 1952, pp. 73–102. 5. Gutierrez-Mahoney, C. de G., and Carini, Esta: Neurological and Neuro- surgical Nursing. St. Louis, C. V. Mosby Co., 1949, pp. 26–88. 6 McLester, James S.: Nutrition and Diet in Health and Disease. Philadelphia, W. B. Saunders Co., 1950, pp. 677–686. CHAPTER 38 Brain Tumors (INCLUDING BRAIN ABSCESS, TUBERCULOMA, SUBDURAL HEMATOMA, AND ANEURYSMS) The diagnosis and treatment of intracranial tumors constitute one of the most fascinating branches of surgery. The names of Horsley, Cushing, and Dandy will always bring to mind the ad- vances in neurosurgery which have so brightened the once hope- less outlook for the many people afflicted with brain tumor. Since all intracranial space-occupying lesions produce similar symp- toms and signs, it is practicable to include in the consideration of brain tumors not only neoplasms but also brain abscess, tuber- Culoma, and subdural hematoma. CLASSIFICATION Classification may be made in two ways, either by the nature of the pathologic process or by its location, both of which are Important. Gliomas. From the point of view of pathology the glioma is the Commonest type, accounting for about half of all brain tumors. There are several varieties of glioma but certain features are com- mon to all. Glial tumors arise mainly from the various types of supporting cells which are found in the brain. All glial tumors are malignant in that they are invasive, but, unlike malignant tumors arising from other tissues, they have never been known to metastasize to distant regions of the body. Contributing to the difficulty in treating these tumors surgically are: (1) the similar- BRAIN TU MORS 423 ity in their gross appearance to that of brain tissue, so that it is hard or sometimes impossible to define the tumor boundaries; and (2) the frequent location of glial tumors in a portion of the brain essential to life. Although they are usually invasive and non-encapsulated, many gliomas grow so slowly that their recur- rence and repeated removal are compatible with many years of useful life. Meningioma; Acoustic Neurinoma. Tumors arising from the membranous covering of the brain or from the sheaths of the cranial nerves constitute the next largest group of brain tumors. These include the meningioma and the acoustic neurinoma, which are benign tumors causing symptoms and signs by pressing upon the brain. Tumors of Pituitary and Pineal Origin. Other true tumors are those arising from the pituitary and pineal glands. These may be benign or malignant. It must also be remembered that malignant tumors arising from other parts of the body may metastasize to the brain. Brain Abscess; Tuberculoma; Subdural Hemaforma. Brain ab- Scess and tuberculoma are not neoplastic, but are lesions of infec. tious origin. Subdural hematoma, the presence of blood between the dura and brain, is neither neoplastic nor infectious, but prob- ably traumatic in origin. SIGNS AND SYMPTOMS Brain tumors produce symptoms and signs in three chief ways: (1) by pressing upon and damaging the adjacent portion of the brain, often giving rise to localizing signs; (2) by increasing the Contents of the Cranium, thus causing increase in intracranial pressure; (3) by interfering with the mechanics of the cerebro- spinal fluid system, causing hydrocephalus. Increase in intra- Cranial pressure has been discussed under intracranial injuries (p. 415). It is the slowly progressive form which is usually pro- duced by brain tumors. Hydrocephalus. This condition, Commonly known as “water on the brain,” is an integral part of any discussion of brain tumors since such tumors frequently produce hydrocephalus. Ob- struction to the flow of cerebrospinal fluid from the ventricles results in dilatation of that portion of the ventricular system which is obstructed (internal hydrocephalus). Interference, either Complete or partial, with the absorption of cerebrospinal fluid over the surface of the brain, may produce large pools of fluid on 424 NURSING IN NEUROLOGIC SURGERY / Ventriculoscope º 4-5. C śAf zº - Zºst- g- Probe \ = N *= \ sº * R N \ = -- y Cºf S. 3. 3: Choroid plexus I Ny Cautery FIGURE 109. Electrocoagulation of the choroid plexus in the treatment of hydro- cephalus (choroid plexectomy). the outside of the brain (external hydrocephalus) as well as cause enlargement of the ventricular system. The ventricles enlarge at the expense of brain tissue, and if the hydrocephalus persists, eventually the brain tissue becomes thinned out and functionless. Hydrocephalus may be caused by tumor, congenital abnormality, or infection (e.g., meningitis). The removal of an obstructing tumor, if carried out before the damage to the brain is too great, will result in the cure of hydro- cephalus. Operation designed to make new openings into the ven- tricles (ventriculostomy) or to reduce the amount of fluid se. creted (choroid plexectomy) or to create an artificial shunt of fluid into another body cavity (ventriculopleural, ventriculoperi- toneal, or ureterosubarachnoid) is occasionally successful in cur- ing hydrocephalus due to Congenital or infectious types of obstruction. Frequently, however, in the congenital forms the brain is so badly damaged, and other abnormalities so often occur in conjunction, that little is to be expected in the way of perma- nent improvement. DIAGNOSIS Localizcation The function of many portions of the brain is known, but there are also large portions, especially of the cerebral hem- BRAIN TU MORS 425 L. half of field Optic chiasrn Retina Occipitol lobes Optic N. R. half of field FIGURE 110. The visual pathways. The lens of the eye causes the retinal image to be inverted. ispheres, for which no function has been definitely determined; these are the so-called silent areas. Thus the cerebral areas Con- Cerned with motor function, sensation, and vision are known, but many of the functions of the temporal and frontal portions (lobes) of the hemisphere are not definitely known. It is possible to remove large portions of these lobes without bringing about any measurable changes in the individual. The functions of the many long fiber tracts transmitting nerve impulses are known, as are also the functions of the Cranial nerves. If a tumor is so situ- ated as to compress or damage a portion of the brain of known function, neurologic examination of the patient reveals altera- tion of function. It is not often, however, that localization is so easily accomplished. Tumors may be situated in the silent areas: and even when a certain fiber tract is observed to be damaged, it is not always possible to know with certainty which portion of the long tract is affected. Certain observations, nevertheless, are worthy of mention. Epi- leptiform convulsions point to a cerebral lesion, and if the con- vulsions are confined to or always originate in one portion of the body (Jacksonian epilepsy), the lesion is in the opposite cerebral hemisphere. Weakness or paralysis of a part or all of one side of the body indicates injury of the motor nerve tract leading finally to the cerebral cortex of the opposite side, but the exact point of damage must be determined by additional observations. Similarly, 426 NURSING IN NEUROLOGIC SURGERY Injection of air 22-2 into ventricles- to replace cerebrospinal fluid FIGURE 111. Ventriculography I. Replacing fluid in ventricle with air. signs of partial or complete loss of sensation are useful for local IZat1OIl. Tumors affecting the visual pathways can be localized accu- rately since the characteristic functions of the different portions of the tracts are well known. Figure 110 explains how a tumor in- volving one optic nerve will cause blindness of that eye, whereas a tumor in the left occipital lobe will cause loss of the right half of the visual field of both eyes (right homonymous hemianopsia), and a tumor at the optic chiasm (i.e., a pituitary tumor) will result in loss of the lateral half of the visual field in both eyes (bi- temporal hemianopsia). Again, a tumor in the cerebellopontine angle characteristically causes deafness (paralysis of the eighth nerve) and loss of sensation and motor power over that half of the face on the same side (paralysis of the fifth and seventh nerves). Unfortunately, despite the large amount of information avail. able, only a small percentage of brain tumors can be localized with certainty by means of neurologic examination. Exact locali zation, nevertheless, is of vital importance to the patient, as there is grave danger in making an incorrect exposure of a brain tumor. Since the epochal discovery of ventriculography by Dandy in 1918, untold lives have been saved by the accuracy with which this method localizes nearly all brain tumors. Ventriculography Through an operative opening (trephine) made in the skull, usually in the occipital region, a needle is inserted into the pos terior portion (horn) of one or the other lateral ventricles. In some clinics frontal or parietal openings are made. The cerebro BRAIN TUMoRS 427 Figure 112. Ventriculography II. Roentgenograms. Upper, normal; lower, hydrocephalus. 428 NURSING IN NEUROLOGIC SURGERY spinal fluid is replaced with air, and stereoscopic roentgenograms are made with the patient's head in various positions. It is thus possible to visualize the contour of the whole ventricular system. Tumors which occupy space within the cranium cause charac- teristic alteration of the normal appearance of the ventricles. For example, a large tumor compressing the cerebrum from without causes a dislocation of the lateral and third ventricles toward the opposite side, whereas a small tumor in the brain substance of the frontal lobe bulges into the anterior horn of the ventricle on that side, causing obvious alteration in the outline of that horn. A third type of abnormality is dilatation of the ventricles (in- ternal hydrocephalus), resulting from obstruction to the outflow of cerebrospinal fluid. The technic of ventriculography is difficult, and is safe only in the hands of the specially trained surgeon. The air is irritating to the brain and must be removed promptly. As in all surgical pro- cedures, asepsis is of the utmost importance. Pneumoencepholography Air may also be introduced into the cerebrospinal spaces through spinal puncture but this procedure may be dangerous and should not be used in the presence of increased intracranial pressure; it is of limited value therefore in the localization of tumors and finds its chief field of usefulness in the demonstration of atrophic lesions of the brain. The subarachnoid spaces as well as the ventricles are usually filled with air in this procedure, thus enabling the surgeon to visualize to some extent the surface of the brain as well as its interior cavities. Air so injected is slowly absorbed, disappearing in about twenty-four hours. The head- ache which results from this procedure is less severe if the patient is kept flat in bed. Arferiography A radiopaque material, usually 35 per cent Diodrast (but sometimes also Thorotrast), may be injected into the carotid arteries for x-ray visualization of the major cerebral vessels. This may be done by the direct or open method in which the carotid artery is exposed in the neck and injection carried out under direct vision, or by the closed or percutaneous method in which a needle is inserted into the carotid artery through the intact skin. The latter is the simpler and more commonly used method. The technic is extremely useful in visualizing vascular abnor- malities such as aneurysms, arteriovenous fistulas or arterial and BRAIN TUM(ORS 429 ~~~vv^^^^^^^^^^^wº-y B FIGURE 113. Electroencephalography. A, Normal record; B, record characteris- tic of epilepsy (petit mal type). venous occlusions. Tumors in the frontal and temporal areas can also sometimes be accurately localized by this method. Electroencephalography There are definite rhythms of brain electric potentials which vary in different parts of the brain. These rhythms can be charted and abnormalities that point to a cerebral lesion studied. This field is being intensively studied and is contributing more and more to our knowledge of normal and pathologic functions of the brain. NURSING CARE During the admission procedure the nurse, in acquainting herself with the patient, should find out the nature and extent of his disability so that she can plan his nursing care. When the diagnosis is epilepsy, the patient usually brings to the hospital the drugs he has been taking; any information concerning these should be given to the surgeon. Patients with brain tumor some- times have convulsions. It is advisable, when inquiring, to refer to these seizures as fainting spells, for the word convulsion or fit carries a stigma in society. The nurse should be thoroughly familiar with the care required by patients who have epilepsy." In helping the surgeon perform a physical examination, neces- Sary equipment includes a sphygmomanometer, tuning fork, 1 See Brown, pages 732–741. 430 NURSING IN NEUROLOGIC SURGERY straight pin, cotton, small soft brush, tongue blades, stethoscope, tape measure and individual vials of solutions containing vine- gar, cloves, sugar, benzine and peppermint. The student is re- ſerred to a description by Brown” ſor explanation of the examination of the cranial nerves. Other diagnostic examinations frequently done are the lumbar puncture and Queckenstedt test.” After the patient is undressed, his skin should be inspected. Bruises may be indicative of injury incurred by falling during a convulsion. The patient who has a diagnosis of tumor should be carefully examined about the hairline and neck ſor furuncles and, iſ any are present, the surgeon should be notified. Such an inſection would necessitate postponing any intracranial opera- tion because of the great risk of carrying infection into the brain. Assuring the patient and the family in a warm and interested manner that all will be done for the patient that is possible is helpful in relieving some of their anxiety. Preoperatively, the patient may have many examinations. The most Common are arteriogram, ventriculogram, encephalogram, electroencephalogram and audiogram. No special physical prep- aration is needed for electroencephalogram or audiogram, but the patient should understand what will take place during either of these. An audiogram may be described simply as a hearing test, but when an encephalogram is ordered, the patient should be told that small wires will be placed on his scalp and that they will not cause pain. Further explanation will depend on the age and interest and anxiety of the patient. Often patients have had such examinations previously; it is always useful to find out first what experience the patient has had. Preparation for arteriogram usually consists of withholding fluids and food several hours before the examination. Diodrast, 35 per cent, is injected into the internal carotid artery to permit visualization of the intracranial arterial system on roentgeno- grams. Some individuals are sensitive to this drug; one method of determining sensitivity is by placing 2 cc. of the solution under the tongue. An unfavorable reaction is evidenced by red- ness and swelling of the tongue. To protect the safety of each patient, a tracheotomy set must be at hand in case laryngeal edema or spasm develops. Following the procedure, the dressing on the neck should be inspected for bleeding or swelling from a hematoma. General 2 Op. cit., page 716. - 3 Op. cit., pages 719–720. BRAIN TUM ORS 431 care will depend on whether the procedure was done under local or general anesthesia. Infrequent sequelae are unilateral weakness and aphasia. The nurse should report these findings to the doctor, and the patient should be assured that these are transient, usually disappearing entirely in six to twelve hours. Preparation for encephalography and ventriculography is the same as that for general anesthesia. Following either procedure, the care consists in observing the temperature, pulse, respira- tions, blood pressure and the state of consciousness.” The head- ache following encephalography is excruciating; usually aspirin is ordered to be given either orally or rectally, according to the condition of the patient. When nausea and vomiting occur, fluids are given sparingly. The position of the patient depends entirely on the orders of the surgeon; some surgeons prefer the patient to lie flat, others prefer to elevate the head 6 to 12 inches. TREATMENT Crciniotomy Any surgical exposure of the brain necessitates opening the skull, which is what the word craniotomy means. The neurosur- geon need not be endowed with skill above his brother surgeons if he is aware that small technical errors in this field are followed by large disasters. One careless motion may forever deprive the patient of the use of some portion of his body. Lack of rigid asepsis and hemostasis is fatal. The soft brain does not withstand minor trauma, bacterial invasion, or bleeding as do the other tissues of the body. Technic. Incisions in the scalp are so placed as to be concealed beneath the hair, yet afford good exposure. Two types of open- ing may be made through the skull: (1) decompression, in which the bone is removed permanently, and (2) osteoplastic crani- otomy, in which a flap of bone is elevated, to be replaced at the conclusion of the operation. The first type is used for very small openings, or to relieve intracranial pressure, or in the occipital (cerebellar) region where the heavy neck muscles will cover the defect in the skull and protect the brain. The second type is Commonly used for exposing cerebral tumors. Care is taken to avoid entering the paranasal or mastoid sinuses, as that would lead to infection. The large blood vessels must not be injured since the brain does not tolerate serious interference with its circulation. Following incision of the dura, 4 Brown, pages 720–721. 432 NURSING IN NEUROLOGIC SURGERY * * * 47 'sº-l -—-y > —). Vºl. B º *ITNº º * * sº É Hº-Yº e ~ 뺺-º-º: & Sºº-ji ºr .Nº Wºk-º-º: º >Sºº sº QºS. T. Sº *. . . ºSºº º º:Sºº º a *- :- lº * A §sº º z-z-z-Lº. tº s: U-ºº: sº º ... ', '', . . . . . . . tº: º - tººs --Kº Fºº-ºº: º!— • *. * {} • , º/, ºº::sº º W J º ...: !' . . . . . . .A& #/. yºzººlºº N '.". . . . . ', ' ' . . . . . º º Re-à-2 *...* * . . . ſº Sºs § * = & 4 e t; * SN& tººs VºIV. . . . . . . . . gº § NºS “, .* * ' ' , 4 & • * g ãº- -\Sº SS & .” e - -- º, N #: # f ź Dupal tumor y diseected from brain FIGURE 114. Craniotomy. Insert shows how incision in scalp is concealed be- neath hair. the brain is exposed; it must be kept moist so that the cells on the surface are not harmed. If in the course of removing a tumor a portion of the brain is also removed, the resulting defect is permanent; the space will afterward be filled with cerebrospinal fluid. POSTOPERATIVE CARE In addition to the usual care needed aſter any major operation, the neurosurgical patient requires minute observation in order that the surgeon may detect and treat increase in intracranial pressure and prevent complications which may arise as a result of the patient's state of consciousness or loss of motor function. It must be realized that any operation upon the brain, even when carried out in the most skilful manner, is a form of intracranial injury. There is always some degree of cerebral edema, outpour- ing of fluid, and bleeding. One of these, or at times all of them, may cause a dangerous rise in the intracranial pressure. Relieſ from pressure may be afforded by aspiration of blood and cerebrospinal fluid from beneath the wound, from the cere bral defect, when there is one, or from the ventricles. At times it BRAIN TU MORS 433 is necessary to remove the bone flap to make additional room for the swollen brain. Spinal puncture should be avoided, as with- drawal of fluid from the spinal canal in the presence of high intracranial pressure may allow the lower portion of the brain (medulla) to become compressed in the foramen magnum, with resulting injury to the vital centers. NURSING CARE The preoperative care of the patient with lesions of the brain depends a great deal on the signs and symptoms of the patient, which, in turn, depend on the location of the lesion. Nursing care must therefore be planned individually for the patient. Patients may be emaciated ſrom frequent vomiting, lack of appetite or inability to swallow. Spoon or tube feeding may be necessary and care must be taken to prevent choking and aspira- tion. When there is incontinence of urine and feces special efforts must be made to keep the patient clean and dry. Offering the bedpan or urinal at regular intervals may eliminate a wet bed. Enemas may need to be given if there is fecal incontinence. Ambulatory patients with personality changes, weakness of muscles, or visual disturbances present special problems. Nursing care is directed toward protecting them from injuring them- selves, from disturbing others on the ward as they walk about, and toward raising their morale. Everyone on the neurosurgical ward must help provide a safe environment for these people. They may walk aimlessly about the ward, get lost or, if furniture is misplaced, may stumble and fall. Any change in the state of Consciousness, the occurrence of convulsive seizures, or the de- velopment of a very slow pulse rate must be observed and reported. The immediate preparation for surgery is similar to that for general anesthesia. Sometimes a sedative is given the evening before but this depends on the condition of the patient. In addi- tion to the usual postoperative unit, a suction apparatus should be available. Other necessary equipment is already available iſ the patient goes to the recovery room, but if he returns to the ward the essentials are: a sterile set-up for spinal tap, including manometers, ventricular needles, 50 per cent glucose, ampules of ephedrine and sodium phenobarbital. Following operation, constant observation is necessary for at least twenty-four hours. The temperature, pulse, respirations, and blood pressure are taken every fifteen minutes for the first 434 NURSING IN NEUROLOGIC SURGERY few hours or until the patient has fully reacted. A rising blood pressure and a slowing of the pulse and respirations are indica- tive of increased intracranial pressure. The position of the patient depends upon the desire of the neurosurgeon; some order the head to be elevated 10 to 12 inches to decrease the venous pressure and thereby lessen edema, while others prefer their patients to lie flat in bed. In either case, the patient should be turned on his side to prevent the tongue from falling back, and to allow saliva and vomitus to run out. The position should be changed every hour from side to side until the patient is no longer unconscious or helpless. Fluids are given parenterally until the patient is able to swal- low. In patients unable to swallow, feeding may be by gavage, in which case the formula (p. 50) for use with the gastrostomy tube is suitable. Since there is frequently inability to evacuate the bladder or the bowel, these acts must be done for the patient. When there is incontinence the patient should be bathed after each voiding or defecation. The state of consciousness is determined by the patient's ability to respond. When the patient is unconscious, there is no response to any stimulus; during stupor, painful stimuli will provoke a re- sponse. Sometimes there may be inability to talk because the speech center is affected, but the patient may respond by perform- ing certain acts when requested. Asking the patient to squeeze both hands of the nurse not only tests his orientation but also demonstrates any weakness or paralysis. Observation of the move- ment of the face and legs should be made. Weakness or paralysis may be detected if there is asymmetry of the face when the pa- tient is asked to show his teeth, or if he is unable to move one or both legs. Tremors, convulsions, weaknesses or paralysis should be noted. Memory and orientation are important criteria of the patient's recovery. Following craniotomy there is frequently considerable edema of the tissues of the head which may lead to closure of both eyes. Cold compresses are then indicated to reduce swelling. The Corneal reflex is tested with a wisp of cotton and when it is im- paired the lids are frequently sutured shut (tarsorrhaphy), or irrigation and ointment followed by an eye shield may be ordered. The irresponsible behavior of the semiconscious patient re- quires watchfulness. He may try to get out of bed, take off the head bandage, or remove the urethral catheter; his conversation BRAIN TUM(ORS 435 may be uninhibited. Such a patient should be protected from visitors except those of the immediate family. Aphasic patients who are having difficulty either in understanding or in expressing themselves, or both, are particularly in need of help and en- couragement. As the patient progresses in his recovery, he should be encour- aged to do things for himself in so far as he is able. Bathing him- self should be encouraged, but if the patient is irresponsible close supervision is necessary. The patient is gotten up according to his condition, sometimes as early as the second or third day. If he has some weakness in either of his extremities, a walker is of value to lend support and confidence. Any change in the state of consciousness, fever, blood pressure, pulse or respirations during his convalescence may be signs of severe complications. These need to be reported to the surgeon immediately because immediate attention is called for. During the convalescent period, plans should be made as soon as possible to prepare the patient for life outside the hos- pital. When a large tumor has been removed, there is frequently slow progress in ability to think, remember, and to give self- care. The family or those who will be responsible for the patient must be encouraged and told that improvement may be slow but often there is greater ability to adapt at home in familiar sur- roundings. Women are usually sensitive about their shaven head; an at- tractive turban worn until the hair grows out allows them to go about the ward and to leave the hospital without feeling con- spicuous. Before the patient leaves the hospital the scalp should be cleaned with oil to remove crusts and a shampoo given. The plans for home care of some patients require the need for further nursing care, either full-time or by a visiting nurse. The social worker can often give valuable help to the family in preparing for the care of the patient. BRAIN ABSCESS; TUBERCULOMA An abscess in the brain, resulting from the extension of infec- tion from mastoiditis or sinusitis or from bacteria deposited in the brain by the blood stream, produces the symptoms and signs of brain tumor, since the abscess and surrounding inflammatory swelling occupy space within the skull. Multiple brain abscesses are almost always fatal, with death usually resulting from in- creased intracranial pressure. A solitary abscess may be cured by 436 NURSING IN NEUROLOGIC SURGERY drainage or by simple tapping of the abscess. Antibiotics are used in treating brain abscesses with dramatic results. Similar inflam- matory tumors are caused by tuberculosis; these tumors are usu- ally multiple, and cure is becoming more frequent with chemo- therapy and antibiotic therapy. SUBDURAL HEMATOMA This moderately common lesion is probably always traumatic in origin. Usually a slight blow on the head, so trivial as to be quickly forgotten, is responsible for a slow hemorrhage due to in- jury of a vessel on the surface of the brain. The free blood lies between the dura and the arachnoid and gives rise to signs of cerebral compression. Absorption in the subdural space is ex- tremely poor and the hematoma may actually increase in size be- cause of fresh hemorrhage or the high osmotic pressure of the hematoma. Subdural hematomas are bilateral in about 15 per cent of the cases and give rise to such symptoms as loss of mem- ory, speech difficulties and dizziness. In children, particularly those with scurvy, subdural hematomas frequently develop which are usually bilateral. Accurate diagnosis is made by ventriculog- raphy, and evacuation of the subdural blood results in cure. INTRACRANIAL ANEURYSMS There is, in man, only one place in which an artery courses directly through a vein, and that is where the carotid artery passes through the cavernous venous sinus in the base of the skull. Not infrequently this region is damaged when the skull is fractured, and such an injury results in the formation of a carotid-cavernous arteriovenous aneurysm. Characterized by a loud cranial mummur (bruit) usually heard by the patient, these aneurysms cause serious interference with the circulation of the brain and face, and produce a striking pulsating exophthalmos on the same side. Another type of arteriovenous aneurysm, the Cirsoid, occurs on the surface of the brain. These aneurysms are of congenital origin, and usually cause convulsions. Small arterial aneurysms occur in the branches of the small arteries at the base of the brain. These too are usually congenital, and may cause hemor- rhage of a serious nature. The only cure for any of these aneurysmal lesions is occlusion of the vessels involved, when this is possible. BRAIN TU MORS 437 SUMMARY Brain tumors and other space-occupying lesions within the cranium cause symptoms by Compressing and/or damaging a portion of the brain. In addition to neurologic examination, spe- cial technics of examination include ventriculography, arteriog- raphy, and electroencephalography. Personality changes and other disabilities before and after operation require special nursing skill. VOCABULARY REVIEW glioma hemianopsia paralysis meningioma trephine aphasia hydrocephalus pneumoencephalography tuberculoma crantotomy SUGGESTED READING . Cecil, Russell L., and Loeb, Robert F.: A Textbook of Medicine. 8th Ed. Philadelphia, W. B. Saunders Co., 1950, pp. 1470–1482. . Dandy, Walter E.: Surgery of the Brain, in Lewis' Practice of Surgery. Hagerstown, W. F. Prior Co., 12:1–682, 1932. . Dotter, Pamela, and Wade, Eleanor: Brain Tumor. Am. J. Nursing, 51: 300–303 (May) 1951. . Krause, Marie V.: Nutrition and Diet Therapy. Philadelphia, W. B. Saun- ders Co., 1950, pp. 333–341. . Penfield, W., and Steelman, H.: The Treatment of Focal Epilepsy by Cor- tical Excision. Ann. Surg., 126:740–762 (Nov.) 1947. . Pilcher, Cobb: Preoperative and Postoperative Care in Neurosurgical Pro- cedures. Arch. Surg., 40:1176–1184 (June) 1940. . Rand, Carl W.: The Neurosurgical Patient. Springfield, Charles C Thomas, 1944, p. 442. . Roseman, Ephraim, and Taylor, Anne: Progress in the Treatment of Epilepsy. Am. J. Nursing, 52:437–440 (April) 1952. Walker, A. E., and Johnson, H. C.: Surgical Treatment of Epilepsy. Am. J. Surg., 55.200–218 (Jan.) 1948. . Walker, A. E.: Treatment of Epilepsy by Cortical Excision. J. Pediatrics, 38: 285–298 (March) 1951. CHAPTER 39 Surgery of the Cranial Nerves The cranial nerves are often affected in both intracranial in- juries and brain tumors. Some of the nerves are more sensitive to pressure than others. For example, double vision (diplopia) caused by injury to one or more of the special motor nerves to the eye muscles, is often an indication of general increase in intracranial pressure, but corneal anesthesia is caused only by direct involvement of the trigeminal nerve or its nucleus in the brain stem. Unless the nerve has been permanently damaged, the successful removal of a tumor or the relief of pressure is followed by complete restoration of function. Of all the cranial nerves the tenth or vagus nerve is the only one carrying impulses essential for life. If the vagus nerve is destroyed on one side only, there will be paralysis of the vocal cord on the same side, with Consequent disturbance of phonation, and serious interference with the mechanism for swallowing. The latter difficulty may necessitate tube feeding. Destruction of both vagi is followed by respiratory difficulty (paralysis of both vocal cords) and inability to swallow without aspiration (loss of cough reflex and paralysis of glottis). Tumors in the cerebellopontine angle often involve the tenth nerve as well as the fifth, seventh, and eighth, and the outcome depends upon the success of the surgeon in saving the tenth nerve. Paralysis of the facial muscles (which are innervated by the seventh cranial nerve) is another frequent complication asso- ciated with these tumors, as it is also with fracture of the skull and mastoid infection. When destruction of the intracranial portion of the facial nerve has occurred it is possible to secure partial return of function by anastomosing the extracranial por- tion of the facial nerve to the central portion of another nerve, usually the spinal accessory or the hypoglossal. When successful, this procedure restores tone to the paralyzed facial muscles, thus improving facial expression, and often a patient learns to control the newly innervated muscles quite well. There is, of course, paralysis of the trapezius muscle when the eleventh nerve is used for this purpose, but no serious deformity or disability results. 438 SURGERY OF THE CRANIAL NERVES 439 A. lmcision for temporal approach to ºf Cliºſ lº! | j 1. *º *ss see*s SIncision y ſ|| s t § wº lar º * FIGURE 115. Surgical treatment of trigeminal neuralgia. A. Temporal approach to N. W.; B, cerebellar approach to N. V. TRIGEMINAL NEURALGIA The cause of this common and extremely painful affliction, also known as tic douloureux, is not known. Symptoms. Trigeminal neuralgia is characterized by frequent attacks of almost unbearably severe pain occurring in the dis- tribution of one or more of the branches of the fifth cranial nerve. The pain is sudden, shooting, or stabbing, and there is often a small area of face or tongue (trigger zone) the stimula- tion of which starts up an attack. Occasionally the pain is bi- lateral in distribution, indicating that both nerves are affected. Treatment. The attacks may be abolished by any procedure 440 NURSING IN NEUROLOGIC SURGERY which renders the nerve functionless. This may be accomplished in three ways: (1) by injection of alcohol into a part or the whole of the nerve; (2) by division of the branches of the nerve as they issue from the skull; and (3) by division of the nerve within the skull. In recent years a fourth method, namely, section of the pain fibers to the face within the medulla, has been devised. Tactile sensation would be spared by this procedure. However, the hazards of the operative procedure, along with the certain damage to contiguous structures, make the disadvantages far out- weigh the advantages. Of these methods, the third is followed by the fewest complica- tions and recurrences. The muscles of mastication need not be paralyzed, and at times some sensation in the face and tongue of the affected side is preserved. One constant and enduring hazard after the operation is the anesthesia of the cornea which follows destruction of the nerve. The natural protective mechanism of the cornea is thus rendered deſective, and corneal ulceration some- times occurs, particularly when proper care is not taken to pro- tect the eye at all times. Nursing Care. The nurse should teach the patient to be respon- sible for the protection of his eye. A daily boric acid eye wash to cleanse the eye and the wearing of glasses fittted with a side shield to prevent foreign bodies from coming into contact with the eye help to prevent corneal irritation. The patient should be taught to look into every mirror he passes to detect any abnor- mality. Herpes of the lips and face, originating from trauma, is an- Other complication which is often very annoying. If this condi- tion is persistent the nurse should help the patient to select a bland diet to prevent irritation. Sometimes the patient may complain of losing particles of food between his teeth and cheek on the affected side. Until he is accustomed to the loss of sensation on the side of his face he should be warned to take care while eating to avoid biting his cheek. Good oral care should be emphasized by teaching the pa. tient to cleanse his mouth after each meal. GLOSSOPHARYNGEAL NEURALGIA A rare ſorm of tic involves the ninth nerve (glossopharyngeal) instead of the fifth nerve. In this form the distribution of the pain is limited to the portion of the pharynx supplied by the ninth SURGERY OF THE CRANIAL NERVES 441 nerve, but the pain is of the same type. Cure of this form is also effected by division of the appropriate nerve within the skull. MéNIERE's DISEASE Somewhat less frequent in occurrence than tic douloureux, Ménière's disease is an affection of the eighth cranial nerve. Symptoms. Since this nerve is composed of two parts, the auditory branch which transmits the impulses of hearing from the ear, and the vestibular branch, which carries the impulses of equilibrium from the semicircular canals, two types of symptoms may be expected: (1) gradual loss of hearing (deafness) and noise in the ear (tinnitus); and (2) attacks of violent dizziness (vertigo) accompanied by nausea and vomiting. The attacks vary greatly in frequency, intensity, and duration. When severe they are incapacitating. The sensation is familiar to those susceptible to seasickness, or to those who remember the childhood experi- ence of unwinding rapidly in a twisted rope swing. The vertigo is at times so severe as to cause the patient to feel as though he had been thrown to the ground. The deafness and tinnitus may be in- tensified during attacks. This disease also is occasionally bilateral. Treatment. Cessation of the attacks of vertigo results from the division of the vestibular branch of the eighth nerve within the skull. Restoration of hearing does not follow operation, but whatever hearing the patient may have had may be preserved. The attacks of vertigo do not recur. During the immediate post- operative period, however, the patient may have intense dizzi- ness, which gradually diminishes within a few hours or a few days, at most. Tinnitus is frequently abolished or improved. Other forms of treatment such as a salt-free diet or histamine injections may give temporary relief to some patients. Nursing Care. The postoperative care should include close Ob- servation of the temperature, pulse and respirations. The patient Sometimes has difficulty in voiding. Warming the bedpan, turn- ing on the spigot so there is the sound of running water, and allowing the patient as much privacy as is possible help him to void voluntarily. If this is not successful the surgeon's permission may be sought to permit the patient to sit up in bed. This may be Contraindicated, or the surgeon may prefer that the nurse give the patient an enema. Since only a small amount of hair on the posterior part of the Scalp has been shaved, in women the hair is often tangled and 442 NURSING IN NEUROLOGIC SURGERY matted when the head dressing is removed. Dampening the hair with 70 per cent alcohol makes combing much easier. Atttempting to walk at first often proves difficult because of the loss of balance on the operative side. When the patient stands or walks he feels that he is being pulled toward the side of operation. Teaching him to walk along the corridor with his hand against the wall prevents him from falling. He must be taught that he should learn to retain his balance by depending on his eyes. This patient needs frequent words of reassurance because at times he appears to have complete lack of confidence in himself. SPASMODIC TORTICOLLIS This curious condition, known also as wryneck, is very dis- tressing. Spasmodic contraction of the muscles of the neck in- nervated by the spinal accessory nerves (eleventh cranial nerve) and the upper pairs of cervical spinal nerves produces grotesque deformity and disability. The cause of the condition is not under- stood. Surgical treatment is designed to paralyze the affected muscles by dividing the spinal accessory nerves and the upper cervical nerves. The resultant deformity and disability, however, may be considerable. SUMMARY The important functions of the twelve pairs of cranial nerves are especially apparent when the nerves are affected by injury or disease. Trigeminal neuralgia and Ménière's disease are common afflictions and can be cured by surgery. VOCABULARY REVIEW diplopia tinnitus torticollis tic douloureux vertigo SUGGESTED READING 1. Christopher, Frederick: A Textbook of Surgery. 5th Ed. Philadelphia, W. B. Saunders Co., 1947, pp. 524–532. 2. Dandy, W. E.: Ménière's Disease, Its Diagnosis and Treatment. Arch. Surg., 16:1127–1152, 1928. 3. Fedder, Helma: Trigeminal Neuralgia. Am. J. Nursing, 48:370–371 (June) 1948. 4. Green, Robert E., and Douglass, Carleton C.: Intracranial Division of thc Eighth Nerve for Ménière's Disease; A Follow-up Study of Patients Oper ated on by Dr. Walter E. Dandy. Ann. Otology, Rhinology and Laryngology, 60:610–621 (Sept.) 1951. SURGERY OF THE SPINAL CORD 443 5. Merritt, H. Houston: Trigeminal Neuralgia. Am. J. Nursing, 48:368–370 (June) 1948. 6. Walker, A. E.: Relief of Facial Pain. M. Clin. N. America, 29:73–97 (Jan.) 1945. CHAPTER 40 Surgery of the Spinal Cord Much that has been said about the brain (p. 41 l) applies equally to the spinal cord. It, too, is a soft structure composed of nerve cells and fiber tracts, invested by the same membranes, and en- closed in a nonexpanding sheath, the spinal canal. The cord is as susceptible to damage from compression as is the brain. The motor nerves and fibers are more easily damaged than are the sensory, but in time both are affected. Fracture and dislocation of the spine are often complicated by injury to the spinal cord. The most important consideration is the realization that, since such damage to the Cord as has already occurred is irreparable, no further damage must be per- mitted: therefore, the utmost care must be taken in transporting patients with spinal injuries and in carrying out therapeutic pro- cedures. Traumatic Paraplegia. Although severe injuries to the spine which damage the spinal cord and result in paralysis of the ex- tremities have always occurred in civilian life, the rapid ac- cumulation of large numbers of such patients during World War II served to ſocus attention on the problem. When the injury is in the cervical region, with paralysis of all four extremities and of all of the muscles of the chest and abdomen, the patient does not survive long. Injuries resulting in paralysis of the lower extremities only are compatible with life. The chief problems involved are the care of the lower urinary tract, the avoidance of decubitus ulcers, the maintenance of nutrition and the re- habilitation of the individual." DIAGNOSIS OF SPINAL CORD INJURIES Localization. Pain is a Common symptom since the spinal nerves are often affected and the distribution of the pain is often 1 Brown, pages 766–790. 444 NURSING IN NEUROLOGIC SURGERY a localizing sign. The segmental distribution of the spinal nerves helps in the localization of cord lesions, since alteration of func- tion may occur in those portions of the body which are served by spinal nerves situated at the site of the lesion or below it. For example, a tumor or an injury in the midthoracic region may cause loss of sensation in the legs and the loss of motor function of the legs, together with disturbance of bladder and rectal Con- trol, but there will be no impairment of the function of the arms. Queckensted: Sign. When a tumor has filled the available space in the spinal canal and the cord is compressed, obstruction to the flow of cerebrospinal fluid occurs. This spinal block can be observed by the absence of response to compression of the jugular vein, which normally causes a rise in spinal fluid pressure, as measured by spinal puncture (Queckenstedt test). The location of such a block can be visualized by roentgenograms taken after the injection of radiopaque oil into the spinal canal. HERNIATED NUCLEUS PULPOSUS Another complication of spinal injury, now frequently recog- nized, is rupture or dislocation of an intervertebral disk. Com- monly causing low back and sciatic pain, this lesion may also simulate a spinal cord tumor. The proper treatment is removal of the disk. Postoperative Nursing Care. After the operation the patient is placed in a bed which has had a fracture board placed beneath a regular mattress. The patient usually has severe pain in his back which may be relieved by opiates. Turning should be en- couraged at least every hour; the nurse should assure the patient that he will not injure his back while turning. The dressings are examined frequently for bleeding. The ability of the patient to move both his legs with equal ease, and the presence of sensa- tion in both legs should be carefully noted. The male patient often has difficulty in voiding. When all the measures that en- Courage voiding such as turning on the water in the room, and the giving of an enema or Prostigmin fail, the surgeon may per- mit the patient to stand up or to sit on the edge of the bed. The surgeon usually orders that the patient wear a corset after he is discharged. The corsetière should measure the patient a day or two after operation so that the final fitting may be made the day he leaves the hospital. Conservative postoperative treatment Consists in advising the patient not to return to work for three months and to refrain from lifting in the interim. SURGERY OF THE SPINAL CORD 445 5pinal cord lntervert. disc Herni ated nucleus pulpos us compressing nerve root ſ #3:2 \\ B. ce: E: Es S& ºv- [s é==###########, ###### S$5. ==Eºf E= * E Nº-Eº es > Hºº & ºsº s ransv. proc. Cauda equina =#a Śās àºff-5up, artic. pro8. &=>TEPºs=E sº Cº- Žsº-E E º & it, SE 5pinous proë. FIGURE 116. Herniated nucleus pulposus (ruptured intervertebral disk). TUM ORS OF THE SPINAL CORD The same varieties of neoplastic and infectious tumors are found in the spinal cord as in the brain, and the general plan of treatment is the same. When such a tumor can be removed Com- pletely before serious damage to the cord has occurred, there will be return of function. LAMINECTOMY The spinal cord is exposed surgically by dividing the flat bony processes (laminae) of the vertebrae. The dura lies beneath the bone, and when it is opened the spinal cord and its pairs of spinal nerves are seen floating in spinal fluid. The motor and the sensory root of each spinal nerve are separate as they leave the spinal cord, uniting after they pierce the dura. This anatomic fact makes possible the division of sensory fibers (chordotomy) for the relief of intractable pain without producing paralysis of the affected part. In the closure of laminectomy wounds the bone is not replaced since the thick muscles of the back afford sufficient protection to the cord. As in surgery of the brain, there is no place here for rough handling of tissues, poor hemostasis, 446 NURSING IN NEUROLOGIC SURGERY or lack of asepsis. In the postoperative period certain essential precautions must be observed. Nursing Care Great care must be taken to avoid injuring the spinal Cord by movement of the temporarily weakened spine. Several nurses and/or attendants are needed to turn such a patient. Decubitus ulcers and urinary tract infection must be guarded against, since the sequelae of one or both of these commonly cause death following operation on or injury to the spinal Cord. The nurse needs to be especially watchful and careful when there has been a serious injury to the cord caused by an accident or by an infiltrating tumor. A sponge mattress and a Cradle to elevate the bedclothes at the foot of the bed aid in preventing bedsores. Frequent bathing, massaging, and turning help to pre- vent decubitus ulcers. There should be a definite routine for carrying out the plan of nursing. At no time should the patient be allowed to remain in one position for more than a very few hours during the day or night. The bedclothes should be kept immaculate. Voluntary urination is often inhibited. A hot enema sometimes increases the ability to void. When there is paralysis of the bladder, incontinence may be present with resultant irritation and maceration of the perineal skin. Permanent catheterization and tidal drainage of the bladder may be necessary, even though this often leads to urinary infection. Careful attention should be paid to distention and constipation. Incontinence of feces can be controlled in most cases by the administration of a daily enema given after breakfast. Nursing Care Following Chordofomy. The terminal cancer pa- tient who has unbearable pain from metastases from cancer is the most frequent candidate for chordotomy. Such a patient is usually undernourished, sleeps poorly, and is extremely uncom- ſortable even though large doses of sedatives and analgesics are given frequently. The physical preparation is similar to that for either general or local anesthesia. The patient and/or a member of his family have been informed that the operation will be done to relieve pain, but in so doing the temperature sense will be lost. When a unilateral chordotomy is performed, the patient will have analgesia on the side opposite beginning a few segments down from the operative lesion. A bilateral chordotomy pro- SURGERY OF THE SPINAL CORD 447 duces complete analgesia and loss of temperature sense a little below the level of the operation. In addition, such a patient usu- ally is incontinent for a few days after operation; incontinence is usually not permanent. The release from pain which these patients gain is most grati- ſying, but they and those who care for them must know that thermal burning can take place without the patient's knowledge. Hot water bottles or other heating devices should not be per- mitted. The patient can feel, but the senses of pain and tempera- ture which normally protect against injury have been lost. SUMMARY The most common lesion affecting the spinal cord and its nerves is the dislocation of an intervertebral disk. Serious in- juries usually cause permanent paralysis necessitating long-term care and rehabilitation. VOCABULARY REVIEW paraplegia nucleus pulposus chordotomy Queckenstedt laminectomy analgesia SUGGESTED READING 1. Bruck, Helen: Nursing the Laminectomy Patient. Am. J. Nursing, 51:158 (Mar.) 1951. 2. Cooper, Irving S., Craig, Winchell M., and Kernohan, James W.; Tumors of the Spinal Cord. Surg, Gynec. & Obst. 92:183–190 (Feb.) 1951. 3. Hamby, Wallace: The Hospital Care of Neurosurgical Patients. 2nd Ed. Springfield, Charles C Thomas, 1948, pp. 113–135. 4. Mount, Lester A.: Injuries of the Spinal Cord. Am. J. Nursing, 45: 101–103 (Feb.) 1945. 5. Woodruff, Margaret B.: To Prevent Pressure Sores. Am. J. Nursing, 52:606 (May) 1952. Unit X. SURGERY OF THE EYE, EAR, NOSE AND THROAT CHAPTER 41 Nursing in Ophthalmology Aristotle said that the eye is the chief organ through which objective reality is appreciated and that sight is the most compre- hensive of all the senses. The importance of proper care of the eyes is obvious to all. In addition to disorders peculiar to the eyes, many ocular lesions are manifestations of such systemic diseases as diabetes, hypertension, nephritis, endocrine disturb- ances, syphilis, and brain tumors: indeed, the eye lesion is often the earliest cause of the patient's symptoms so that the ophthal- mologist is the first doctor consulted. Because of the large num- ber of general diseases that affect the eyes, ophthalmology is, per- haps, more closely related to general medicine than any other specialty. Anatomy and Physiology of the Eye. The eye is a slightly oval globe situated within the orbit which, in turn, is a cone-shaped cavity formed by the bones of the skull. The orbit affords pro- tection to the eye from external trauma. Because of the close 449 450 SURGERY OF THE EYE, EAR, NOSE AND THROAT Iris Copnoe, & chambe Limbus Post, chamber a º § Nº gº ** §y's zºº jº ſ &: jº Ch d Dural sheeth | § º: jº \\ ºº:: Orioi #ſº |ij}, § * §: Optic N.—#| # § Retina |; Ağ ; g |*|| &zCocºa FIGURE 117. The eye (cross section of right eye). anatomic relation of the orbit to the adjacent nasal sinuses, bac. teria sometimes pass from infected sinuses through the bony barrier to involve the eye. Within this bony cavity the eyeball itself is held in a cushion of orbital fat which permits motion of the eye and also absorbs shock to the eye. Muscles. Attached to each eye are six muscles, known as the extraocular muscles. For each eye there is one muscle above, one below, and one on each side; these are named superior, inferior, internal and external rectus muscles from their respective posi- tions. Also there are superior and inferior oblique muscles which have a transverse course. These six muscles are innervated by the third, fourth, and sixth Cranial nerves, and they all coordinate to accomplish the simultaneous movements of the two eyes. Eyelids. The eyes are covered anteriorly by the lids, which are made up of skin, muscle (for opening and closing the lids), a stiff Cartilaginous strip called the tarsus, and a thin inner covering of epithelium known as Conjunctiva, which is a continuation of the conjunctiva which covers the globe and is known as the bul- bar Conjunctiva. Glands. The lids contain two groups of secretory glands, the NURSING IN OPHTHALMOLOGY 451 meibomian glands and the glands of Moll. These secrete lubri- cants for the front of the eyeball. At the outer margin of the orbit, just beneath its bony rim, lies the lacrimal gland which secretes the tears that bathe the front of the eye. The tears pass from the lacrimal gland downward toward the inner (nasal) portion of the cornea where they are drained off into the punctum, a small opening at the inner margin of each lid. Each punctum opens into a thin tube (canaliculus) which ends in the lacrimal sac. The lacrimal sac in turn lies in a bony fossa along the side of the nose. From this sac the tears finally pass through the nasal duct into the inferior meatus of the nose where they are absorbed by the mucous membranes. Eyeball. The eyeball itself is a closed sphere about 1 inch in diameter. It is made up of three main coats or layers known as the sclera, choroid, and retina. THE SCLERA. The sclera, or outer protective layer, is the thickest and is composed of fibrous tissue. It forms the posterior five sixths of the globe, the anterior one sixth being formed by the trans- parent cornea. The junction of clear cornea and opaque Sclera is known as the limbus. The anterior portion of the sclera is covered by the bulbar conjunctiva, which is continuous with the conjunctiva covering the inner surface of the lids. r THE RETINA. The retina, or nerve layer, is the innermost coat of the globe. It is a thin tissue composed of the elements (rods and cones), which pick up an image, and the nerve fibers which conduct the image by way of the optic nerve to the brain. The retina covers the posterior two thirds of the globe, being attached posteriorly at the optic nerve and anteriorly at the Ora Serrata where it passes into the ciliary body. The retina has often been compared to the film in a camera because it is the portion of the eye that is sensitive to light. In the center of the posterior portion of the retina there is a 0.5 mm. area known as the macula lutea in which cones alone are found. It is with this area that we are able to see small objects. In the remainder of the retina the rods predominate and only large objects can be distinguished. Vision in the dark, however, is best when using the peripheral area of the retina. THE CHOROID. The choroid, or nutrient layer, lies between the retina and the sclera. It consists of many blood vessels in a sup- porting structure of connective tissue. These vessels bring nour- ishment to the retina, the vitreous humor, and indirectly to the lens. The iris, ciliary body, and choroid are spoken of collectively 452 SURGERY OF THE EYE, EAR, NOSE AND THROAT as the uveal tract, and are so intimately associated that when one portion becomes diseased the others are usually affected also. CILIARY BODY. Anteriorly the choroid passes into the ciliary body, an elevated body from which the lens is suspended by many thin fibers called zonular fibers. The ciliary body has two functions, namely, the formation of the aqueous humor, and the changing of the lens from thin to thick to enable the person to see equally clearly for far and near objects (power of accommoda- tion). IRIs. Continuous with the ciliary body, and hanging behind the cornea like a curtain, is the iris. This is a pigmented mem- brane, circular in form, which gives to the eye its characteristic color (e.g., brown or blue). PUPIL. The iris is perforated in the center by an opening of variable size known as the pupil. Dilatation and contraction of the iris govern the size of the pupil, which in turn controls the amount of light entering the eye. THE MEDIA. The clear translucent portions of the eye, that is, cornea, aqueous, lens, and vitreous, are spoken of collectively as the media of the eye. The lens, a clear biconvex body, is suspended between the aqueous and vitreous chambers. Just in front of the lens lies the 1T1S. The smaller aqueous chamber is the space between the lens and the posterior surface of the cornea. It is filled with aqueous humor, a clear watery fluid which is secreted constantly by the ciliary body. This passes through the pupillary space, brings nourishment to the lens and cornea, and is drained off by the canal of Schlemm in the angle formed by the root of the iris and the periphery of the cornea. The vitreous chamber lies between the lens and the retina and is filled by a gelatinous substance called the vitreous humor which is largely responsible for maintaining the shape of the eyeball. Image Formation. The optic nerve passes from the posterior pole of the eye through an opening in the orbit into the cranial cavity where it meets the nerve from the other eye and joins the brain. Here the nerves partially Cross and continue backward on each side along the temporal and parietal lobes as the optic tracts and radiations, to end finally in the occipital or posterior lobes of the brain. Light rays from an object pass through the cornea, aqueous humor, lens, and vitreous, and are bent (refracted) by NURSING IN OPHTHALMOLOGY 453 these structures so that the rays strike the retina. The stimulus of the light is picked up by the rods and cones, and is carried along the optic pathways of the brain to the occipital lobes, where finally the seen image is registered upon the conscious mind of the individual (Fig. 110, p. 425). METHODS OF EXAMINING THE EYE Much of the eye can be examined directly; even the interior of the eye, because of the transparency of the cornea, lens, and humors, can be visually examined. In addition, careful tests can be made of the functional ability of the eye. The muscles which control the movements of the eye in its orbit (extraocular move- ments) are tested by having the patient observe a moving object, usually the examiner's finger. Pupillary reactions are tested by means of strong light, and by making the patient shift his gaze from nearby to distant objects (accommodation). Instruments. When inspecting the lids, conjunctiva, and Cornea the ophthalmologist may wear a pair of magnifying spectacles (a loupe) or use a special binocular microscope. By means of a fine beam of light projected through the transparent media of the eye from a slit lamp it is possible to detect opacities in the differ- ent media. The retina itself is directly observed by means of the ophthalmoscope; through the peep-hole in this instrument the examiner can see the illuminated retina and its blood vessels. The perimeter is used to outline tthe extent of the visual fields, and the tonometer is used to measure the tension of the globe. REFRACTION By refraction is meant the determination of the refractive error in the eyes of the patient. Refractive error is a term which is used to signify a failure on the part of the various light- transmitting portions of the eye to bring the light rays into a correct focus on the retina. It is the commonest cause of defective vision (poor eyesight). The amount and nature of the existing refractive error are measured both directly and by means of trial lenses. The ophthalmologist can then prescribe for the patient the spectacle lenses needed to bring all the light rays to a proper focus on the retina. When this is done, normal vision is the result. The fundamental refractive errors are myopia, hyperopia, and astigmatism. All of these conditions cause blurring of the image. They may be ſound alone or in any combination. Myopia. Myopia (near-sightedness) is caused by an overlong 454 SURGERY OF THE EYE, EAR, NOSE AND THROAT anteroposterior diameter of the eyeball, which causes the light rays to focus in front of the retina. Hyperopia. This condition (far-sightedness) occurs when the eyeball is too short, so that the rays focus behind the retina. Presbyopia. Presbyopia is a refractive Condition, occurring between the ages of 40 and 43, wherein one is unable to see near objects clearly. As we grow older, the fibers of the lens harden and the muscles that make the lens fat and thin weaken, thereby bringing about a lessening of the power of accommodation. This causes near objects to be blurred and a magnifying lens is then necessary to enable the person to read. At first, a weak lens suf- fices but this has to be strengthened about every two years as the person grows older. If one already uses a glass for distance vision, bifocals will be necessary when he becomes presbyopic. Astigmatism. Astigmatism results from asymmetry of the Cor- neal curvature, so that rays in the perpendicular plane do not focus at the same point as rays in the horizontal plane. Cycloplegics. In all patients under the age of 40 years refrac- tion should be done when the eye is under the influence of a cycloplegic (a drug which paralyzes the muscles of accommoda- tion). In children up to the age of 12 atropine is used; in patients between 12 and 40 homatropine is the cycloplegic employed. After the age of 40 no cycloplegic is necessary because the power of accommodation has become relatively weak. OFFICE NURSING (See also p. 469) When employed as office nurse for an ophthalmologist, the nurse is expected to instil drops, give irrigations, sterilize and care for instruments, drops and supplies, and assist with the re- moval of foreign bodies, other minor operations, and dressings. The eye is an exquisitely sensitive organ; because of this it is necessary to limit the strength of local applications and to be ex- tremely careful in the manner of their application. Afropine Poisoning. In some patients atropine causes toxic symptoms, including flushing of the face, dryness of the throat, skin rash, vomiting, rapid pulse, excitability, and occasionally delirium. A less serious, occasional result of the prolonged use of atropine is a local reddening of the skin of the eyelids. This disappears when use of the drug is discontinued. Individuals who are either very young or blonde or both, seem more susceptible than others. If any of these symptoms appear the doctor should NURSING IN OPHTHALMOLOGY 455 / FIGURE 118. Dressing tray. All items are sterile, and include forceps, lid retrac- tor, iris scissors (for removing sutures), basin containing irrigation solution, irrigating syringe, curved basin, toothpick swabs, cotton and gauze. be notified at once. For patients known to have or suspected of having sensitivity to atropine, scopolamine hydrobromide is used rather than atropine. INJURIES AND THEIR COMPLICATIONS Foreign Bodies The commonest source of injury to the eyes is due to their constant exposure, and is most frequently encountered in a windy and dusty environment. We have all been through this unpleas- ant experience, some more frequently than others because the reflex that closes the lids varies greatly in speed; people with a slow reflex suffer foreign bodies more often. Many foreign bodies are removed with the corner of a gauze square or a clean hand- kerchief, but this practice should be discouraged because of the danger of introducing infection into the eye. All cases in which the foreign body is stuck firmly require the aid of a doctor. Treatment. The eye is first anesthetized with a drop or two of Pontocaine or other local anesthetic, and the patient is com- fortably seated with his head in a good light. An effort is first made to remove the foreign body with the end of a sterile tooth- pick swab; and if this fails a sterile instrument called a spud must be used to pick the body off the cornea. The spud has a thin narrow blade which can be inserted beneath the foreign body to loosen it from the underlying Cornea. Since the cornea is only 0.5 mm. thick in some areas, great care is necessary to pre- 456 SURGERY OF THE EYE, EAR, NOSE AND THROAT vent penetration of the anterior chamber. In the case of metallic foreign bodies a ring of rust often remains in the substance of the cornea after the metal particle itselſ has been removed; this rust causes a permanent scar if neglected. Its removal is best accomplished by the use of a small dental burr which grinds the rust away while doing the least possible damage to the cornea. Removal of foreign bodies requiring more than minimal manipulation should be followed by the instillation of a lubri- cant into the eye and the application of an eyepad to the eye. In addition, in severe cases atropine should be instilled to pre- vent the traumatic iritis which so often results. These patients should be observed on the day following treatment to be sure that no infection is beginning. Foreign bodies moving at high velocity occasionally penetrate the eyeball. If the damage to the globe is considerable, enuclea- tion (removal of the eyeball) is usually necessary. Small frag- ments of steel or other metals, however, sometimes are driven into the eyeball without causing more than a tiny puncture wound. Such foreign bodies must be removed; this is done by first localizing the foreign body by x-ray and then using a strong electromagnet to draw the fragment out of the globe. Hemciform c. of the Orbit The ordinary “black eye” is of common occurrence. The treatment of this condition consists in the application of Cold compresses for the first twenty-four hours to reduce the bleeding into the tissues. It is, of course, this bleeding that accounts for the discoloration and swelling about the eye. After twenty-four hours hot compresses are applied to hasten the absorption of the blood. The classic remedy of applying a beefsteak to a black eye is in reality nothing more nor less than a form of Compressing. Another old-fashioned remedy, however, applying leeches to a black eye, is harmful because this increases the bleeding instead of checking it. Lacercations of the Lids cind Eye These are not so frequent as might be expected considering the large number of people who wear glasses. The rapid lid-clos- ing reflex saves many an eye when glasses are broken. Lid lacera- tions should be repaired by an ophthalmologist, if one is avail- able, because these lacerations require an entirely different NURSING IN OPHTHALMOLOGY 457 technic than do lacerations in other areas in order to prevent an ugly and damaging V-shaped notching of their healed margin. Lacerations of the globe itself, though infrequent, are most serious because of the likelihood that they will be followed by reduction of the vision. Patients suffering this Condition should be seen by an ophthalmologist as soon as possible, as early opera- tive attention is essential. Wounds of the cornea may be closed by a corneal suture which pulls the lips of the wound together directly, or they may be held together by a conjunctival flap which has been undermined from above or below and drawn over the cornea to cover the wound completely. After the cornea has healed the conjunctival flap is released and it returns to its former normal position. In either case any protruding portion of the inner structures of the eye, such as the iris, lens, vitreous, or uveal tract, must be excised before the wound is closed. Such tissue should never be replaced in the eye because of the danger of introducing infection with it. Lacerations of the sclera and Con- junctiva are closed edge to edge. In the case of scleral perforations, cautery punctures are made around the involved areas in an effort to prevent the underlying retina from becoming detached. Sympathetic Ophthalmic, All lacerations of the globe involving the uveal tract are po- tential sources of further danger. One fourth of one per cent of all such injuries are followed by sympathetic ophthalmia, an ex- tremely serious complication. In this condition the uninjured eye develops a destructive inflammatory reaction which, prior to the introduction of cortisone, always resulted in great reduction of the vision of both eyes. Why or how this occurs is not under- stood. It has not been observed earlier than twelve days fol- lowing the injury to the first eye, and never developed after the early removal of an injured eye. Because of the grave nature of this condition, the possibility of its development in all cases of injury to the uveal tract must be kept in mind, and treatment with cortisone begun at the earliest suspicion. The success of this treatment saves many eyes which in previous years would have been removed. Enucleation. Where sympathetic ophthalmia is suspected or where a laceration has been so great as to have allowed the escape of the contents of the globe, or in cases of malignant intraocular tumor, the eye must be removed. This operation is called enuclea- tion. In it the conjunctiva is incised completely around the 458 SURGERY OF THE EYE, EAR, NOSE AND THROAT limbus and is separated by blunt dissection from the underlying structures. Next, the four rectus muscles are identified and di- vided from their attachments to the globe; sutures are placed in their cut ends. The globe is then separated from Tenon's cap- sule, which is the muscle cone that surrounds the posterior por- tion, back to the posterior pole where the optic nerve leaves the globe. The optic nerve is then divided a few millimeters from the globe so as to be sure not to enter and collapse the globe, and the eyeball is lifted out of the orbit. Bleeding is controlled with warm sponges. A plastic ball, a little smaller than the globe, is placed in Tenon's capsule, the capsule and the rectus muscles are closed over this implant, and finally the conjunctiva is closed. On healing this leaves a useful stump on which can be worn a concave prosthesis, colored to match the other eye. In successful cases movement of this artificial eye is so good that it is difficult to distinguish it from the normal eye. Evisceration. When there is infection within the eyeball, this procedure is used in place of enucleation. The cornea and a thin rim of adjacent sclera are removed; through this opening the contents of the eyeball are taken out, leaving only the sclera. Retincil Defcachment The retina is attached to the underlying structures of the eye only at the anterior and posterior borders. Over the remainder of its surface it is held in contact with the choroid by pressure of the semisolid mass of vitreous humor that fills the vitreous cham- ber. Blows to the eye and degenerative processes produce tears in the retina through which the humor enters; this causes elevation or separation of the thin retina from the choroid. Such an eleva- tion is known as a retinal detachment. The visual field is lost over the area corresponding to the detachment and when the macular area is involved the visual acuity is greatly reduced. In an occasional case the retina will flatten out and become re- attached if the patient is made to lie on his back in bed. Such cures, however, are extremely rare, and in almost all cases surgery Is necessary. In operations for retinal detachment the first object is to locate the tear in the retina. This is done by means of the ophthalmo. scope, and the position of the tear is outlined on the outer sur. face of the eye. After the Sack of the eye has been exposed, elec. trocautery punctures are made through the sclera in such a way as to surround the tear, and the subretinal fluid is permitted to NURSING IN OPHTHALM OLOGY 459 escape either through the puncture holes or, if necessary, through a larger hole made with a knife. When the fluid has escaped the retina can flatten out into its normal position again, and the sterile inflammation produced by the punctures seals off the tear and holds the retina in contact with the choroid. Nursing Care. After operation the patient must remain flat on his back for ten days to allow healing to take place. During most of this time he must have both eyes bandaged to prevent their movement, for such movement might prevent or delay heal- ing. After this he must wear pin-hole glasses; these discourage excessive movement of the eyes by admitting light only through Small central openings, thus permitting the wearer to look straight ahead only. The patient is allowed up and out of bed very gradually and his activity must be curtailed for four to six months after a successful operation. From the above outline of the postoperative treatment it is obvious that this is an unpleas- ant period for the patient. For this reason the nurse can be ex- tremely helpful by making the patient as comfortable as possible, and by offering constant encouragement. Some surgeons are now permitting early ambulation, lavatory privileges, and sitting up in bed. If, as claimed, the end-results in the treatment of detach- ment are equally good, this regimen is preferable. DISEASES Styes A stye is an infection of the small lubricating glands in the margins of the lids. It appears as a red elevation on the lid margin and is painful. Treatment. Yellow oxide of mercury ointment was the time- honored treatment for styes. This gave nothing more than slight comfort and, since the advent of chemotherapy, has been dis- carded. The most helpful form of treatment is the application of hot compresses. The addition of chemotherapeutic drugs lo- cally hastens a successful outcome. In most instances, the inflam- mation subsides, but sometimes suppuration occurs, just as in a furuncle, at which time the stye should be incised and drained. Chcalcızic. A chalazion is a cyst of the meibomian glands of the tarsal plate of the lids. It presents a small lump in the lid which is hard and painless. If infected the redness and pain characteristic of infection everywhere are present here also. 460 SURGERY OF THE EYE, EAR, NOSE AND THROAT Treatment. The infected case is treated by hot Compresses, followed by incision and drainage at the proper time. A small percentage of nominfected chalazia become reabsorbed after massage. In most cases this fails and they must be removed sur- gically. Conjunctivitis This condition can be divided into three large groups accord- ing to causative agents: (1) traumatic (mechanical, thermal, or chemical), (2) inſective, and (3) allergic. The symptoms differ somewhat in the three types but, in general, are as follows: red- ness of the conjunctiva; discomfort varying from a slight feeling of grit in the eyes in mild cases to actual pain in severe cases; lacrimation and photophobia (intolerance to light); marked itch- ing and burning of the eyes in the allergic type; and a purulent discharge in the infective type. Of course, all of these symptoms vary with the severity of the case. Treatment. The history usually serves to separate those cases in the traumatic group. These are treated by the removal of the causative agent followed by irrigations and mild antiseptic drops until the conjunctiva heals. In the infectious group, the specific organism can be isolated and identified by Culture, and the chemotherapeutic or antibiotic agent known to be most effective against this organism is then used. However, since the advent of the wide spectrum chemotherapeutic and antibiotic drugs, the usual method of handling this group is to use the drug of widest spectrum, resorting to culture only in the few cases where this method fails. A solution of zinc sulfate, boric acid, and adrenalin is very effective against the milder forms and every ophthalmologist uses his own variation of this extensively. Antibiotics have greatly facilitated the treatment of the infectious types of conjunctivitis, but occasionally, especially when used indiscriminately, they cause allergies. The third group, allergic forms of conjunctivitis, presents a rather characteristic appearance, being pale and smooth with much itching and no discharge. Antihistaminic or cortisone drops are sometimes helpful, but may prove disap- pointing. Of course, if the allergen can be determined and re- moved, recovery follows quickly. Ophthalmic Neoncitorum Until the instillation of silver nitrate into the eyes of all new- born infants became mandatory, gonorrheal Conjunctivitis was NURSING IN OPHTHALMOLOGY 46 | the greatest single cause of blindness; Credé's procedure greatly reduced the incidence of blindness from this source. Once the dis- ease had developed, its treatment was a formidable ophthalmo- logic problem, and many eyes were lost until the introduction of the sulfonamides and penicillin. In gonorrheal conjunctivitis the eye presents a severely in- flamed appearance, with much swelling and profuse discharge. The eye rapidly closes because of the edema of the lids; later the ulcerated cornea perforates and the eye is lost. Since the advent of chemotherapy, however, treatment has become success- ful. The gonococci disappear within two to four days and the eyes are clear in a week. None of the damaging sequelae that nearly always accompanied longstanding infection is seen now. In treating such patients the nurse must be extremely careful to maintain the strictest isolation technic not only for the safety of others but in her own interest as well. Trachomc. This disease, fortunately, is not very Common in the United States, but it is widespread in China, India, and Egypt, causing blindness in a tragically large proportion of the population. The mode of its transmission is not known, though it has recently been shown to be caused by a virus. It begins as a mild injection of the conjunctiva, followed by the formation of follicles and the ingrowth of fine blood vessels into the superior portion of the cornea. This group of vessels is called a pannus, and is charac- teristic of trachoma. In the later stages of the disease the tarsus of the lids becomes scarred, and as this scarring progresses the lids are inverted (entropion) and the lashes are made to rub on the cornea. Finally the cornea becomes hazy and the vision is greatly reduced. This disease is extremely chronic and the older forms of treat- ment served only to check its progress. Chemotherapeutic and antibiotic agents, however, have been discovered to be dra- matically effective in the treatment of trachoma; indeed, it seems probable that the disease may some day be entirely eradicated. Cornecil Ulcers Any abrasion of the corneal epithelium is a corneal ulcer. Small abrasions may be outlined with the use of fluorescein: if 462 SURGERY OF THE EYE, EAR, NOSE AND THROAT they are uncomplicated they will heal in a few hours without leaving a scar. The only treatment necessary is the instillation of a lubricant such as castor oil to promote healing and to relieve the pain caused by the rubbing of the lids over the denuded Corneal surface. Larger ulcers involve the deeper layers of the Cornea and upon healing leave a scar. The ultimate damage to the visual acuity depends on the position of the scar on the front of the eye, for if it is centrally placed it will be in the line of vision, whereas a peripherally placed scar does not reduce the vision significantly. Corneal ulcers are traumatic or infectious in nature; in some cases a traumatic ulcer becomes infected. Treatment. In the treatment of all but the mildest Corneal ulcers the iris should be put at rest by the daily instillation of atropine. Hot compresses are helpful in all cases and irriga- tions are used when there is a purulent discharge. There are some rare forms of ulceration of the Cornea that Occasionally resist all forms of treatment; the eye may be lost following the perforation of such an ulcer with consequent development of enophthalmitis (inflammation of the interior of the eye). Traumatic Ulcers. Traumatic ulcers are treated by the appli- cation of lubricants and antibacterial ointments and heal rather quickly when no complication occurs. Infectious Ulcers. Ulcers caused by infection take longer to heal but respond well to the application of the chemotherapeutic and antibiotic drugs. In all cases of corneal ulcer, the eye should be covered with an eye pad until the cornea has healed. Kercifitis Inflammation of the cornea is called keratitis. The chief symp- toms of this condition are severe pain in the eye, redness, and watering of the eye (excessive lacrimation). Keratitis may be a Complication of syphilis, tuberculosis, or herpes; in such in- stances, when the cause can be recognized, specific treatment is directed at the causative infection. Often, however, no cause can be found for keratitis. Nonspecific general therapeutic measures are employed in the treatment of patients who have a keratitis of unexplained origin. These measures include the use of atropine, hot compresses, and local application of sulfonamides and antibiotics. Cortisone also is helpful in some instances. NURSING IN OPHTHALMOLOGY 463 Uveitis The inflammation of any portion of the uveal tract is called uveitis. The iris, ciliary body, and choroid constitute the uveal tract. Inflammation of the individual portions of the tract occurs (iritis, cyclitis, and choroiditis), but in some cases the inflamma- tion involves more than one portion. The symptoms of uveitis include redness of the globe which is most noticeable adjacent to the limbus, pain in the eye, photophobia, and a gradual de- crease in the vision. Uveitis may be a manifestation of several general diseases. It occurs along with other signs of the disease, or it may be the first manifestation to appear and in these latter cases it is important that the specific nature of the underlying disease be recognized so that it can be cared for properly. Syphilis and tuberculosis are the two diseases that most frequently cause lesions in the uveal tract. In these the treatment is to be directed at the systemic condition. In addition, hot compresses and atropine drops several times a day are employed locally, as in the case of all types of uveitis. Foci of infection are another cause of uveitis. Where these exist and can be eradicated, the eye will clear rapidly. Here again the hot compresses and atropine to the eye itself are in- dicated. Finally there is a third large group of cases of uveitis in which no definite cause can be found. These are divided into the granu- lomatous and nongranulomatous types. In the granulomatous variety Cortisone is helpful; in some instances the local applica- tion of drops or ointment suffices, but in others oral or parenteral therapy is necessary. Cortisone has little apparent effect in the nongranulomatous uveitis. In these cases the usual local therapy is supplemented by oral administration of the sulfonamides or antibiotics and by foreign protein fever therapy. Salicylates in rather large doses are advised by some ophthalmologists. Foreign Profein Therapy. This is a form of nonspecific treat- ment frequently used in inflammatory conditions of the eye. It consists in the production of an elevation of the temperature of the patient by means of the injection of a protein substance. Typhoid-paratyphoid or diphtheria vaccines given intravenously, or sterile milk injected intramuscularly, are the proteins ordi- narily used. A course of treatment is begun with small doses, in- creasing in amount every other day; the size of the dose and the number of injections are governed by the severity and the tenac- 464 SURGERY OF THE EYE, EAR, NOSE AND THROAT ity of the infection. The patient's temperature should be taken every hour following each injection until it has returned to normal. Codeine may be given during the period of temperature elevation to relieve the discomfort that accompanies the fever. but aspirin and other antipyretics are contraindicated since the production of fever is the object of this form of therapy. Fever of a higher degree can be induced by means of the heated chamber, and this is occasionally employed in the treatment of some eye diseases. Refinitis Inflammation of the retina, also, is caused by many systemic diseases, and the nature of the underlying disease can often be diagnosed from characteristic changes seen in the retina. Diabetes, arteriosclerosis, nephritis, syphilis, tuberculosis, and many other systemic diseases produce retinal lesions. As in the case of uveitis, when the presence of a specific disease can be determined as the cause of the retinitis, the treatment is directed toward the dis- ease. The symptoms of retinitis may be so slight as to escape the notice of the patient unless the macular region of the retina is involved, in which case the vision is seriously reduced. There is no pain, redness, or watering of the eye to call the patient's attention to the presence of the lesion. On ophthalmoscopic ex- amination the fundus shows exudates, hemorrhages, and edema of the retina. Changes in the vision and in the visual fields are present in many cases, and it is usually these that cause the patient to seek help. Papilledemd and Optic Afrophy Inflammation of, or pressure on the optic nerve produces edema of the head of the nerve where it enters the eyeball (optic disk). The swollen nerve head actually protrudes into the eye; this is called papilledema or choked disk. It occurs in diseases which involve the central nervous system, and is also produced by increased intracranial pressure (see Chap. 37, page 416). Fol- lowing prolonged papilledema the nerve fibers die, and the dead- white, flat disk of optic atrophy becomes apparent. In papil- ledema and in optic atrophy the visual acuity becomes progres- sively reduced and finally complete blindness may result. Glaucoma In this disease the pressure within the eyeball becomes too high. Normally the aqueous humor is formed and absorbed at a NURSING IN OPHTHALMOLOGY 465 constant rate. In glaucoma the fluid is secreted more rapidly than it is absorbed, so that the volume of the globe is increased and the intraocular tension is elevated. When this elevation is gradual the symptoms are slight and may not be noticed by the patient until extensive and irreparable damage has been done. When the tension rises rapidly, however, symptoms are severe and cause the patient to seek immediate attention because of the great pain and the loss of vision. An increase in tension causes pressure upon the optic nerve, damaging the nerve fibers and reducing the visual acuity. Such elevation of the tension must be relieved rapidly if permanent damage to the eye is to be avoided. In some cases of glaucoma this can be accomplished by the use of miotics and by the enforcement of rest in bed. The miotics contract the pupil and open the drainage angle of the anterior chamber, thus allowing the normal rate of drainage of the aqueous humor to be resumed. When medical treatment fails to control the tension, more radical surgical treatment must be used. OPERATIONS FOR THE RELIEF OF GLAUCOMA Many types of operation have been devised for the treatment of glaucoma; all have as their common aim the establishment of an artificial passage for the release of excess aqueous humor from the globe and in this manner a reduction of the tension. Iridencleisis, iridotasis, and corneal trephine are the most widely used operations in the treatment of chronic glaucoma. Basal iridectomy is the operation of choice in the acute type, Cyclodialysis in the glaucoma (aphakic) type which follows Cataract extraction, and goniotomy in the Congenital variety. Iridencleisis; Iridotasis. In these two operations a Conjunctival flap is made around the superior portion of the cornea; the globe is entered with a keratome, the iris pulled out of the anterior chamber at this point and deposited on the adjacent sclera; the conjunctival flap is closed with several sutures. Thus a tract is Created along the extruded portion of the iris by which the fluid can escape from the eyeball to be absorbed under the con- junctival flap. The difference in the two operations is only in the handling of the iris. Corneoscleral Trephining. In the trephine Operation a Con- junctival flap is dissected and the underlying cornea is split into two thicknesses. A small opening into the anterior chamber through the deeper half of the cornea is made with the trephine 466 SURGERY OF THE EYE, EAR, NOSE AND THROAT at the limbus. The superficial layer of cornea and conjunctival flap are then replaced and sutured, and on healing there re- mains a small opening through which fluid can escape to be ab- sorbed under the flap of conjunctiva as in the other operations. Basal Iridectomy. In this operation, the anterior Chamber is entered and a large portion of the iris is excised. Cyclodialysis. Quite different in technical detail from the preceding operation, this method provides also a means for fluid from the anterior chamber to escape, but in this instance into a space prepared between the choroid and sclera. Goniotomy. In Congenital glaucoma, there is an abnormality in the angle of the anterior chamber which closes it. This pro- cedure is designed to open the angle mechanically. After-care. All patients with glaucoma should be under the care of an ophthalmologist for the remainder of their lives as no type of operation is permanently successful in all cases, and a recurrence may develop at any time. Often several operations are necessary to bring the tension under control, and sometimes blindness cannot be prevented. Operations for glaucoma usually fail to produce good results in Negroes. This is thought to be due to the racial tendency to- ward excessive scar formation, thus interfering with the con- tinuous function of newly made drainage channels. Cofcircuct A cataract is an opacity of the lens. Cataracts may be con- genital, the result of trauma, or secondary in nature, such as those which occur in diabetes and several other diseases. The common- est variety is the senile cataract. The cause of the senile type is not known, though most experimental evidence on the subject points to some interference in the metabolism of the lens as the underlying factor in its formation. Senile cataract usually begins in the fifth or sixth decade of life, develops slowly over a period of years, and nearly always involves first one eye and then the other. The only symptom of a cataract is the gradual decrease in the visual acuity of the involved eye. This is frequently de- scribed by the patient as a veil drawn over the eye. As the opacity of the lens becomes denser, the vision of the eye grows progressively worse. This process is called maturation of the cataract, and when full maturity has been reached the vision is limited to the perception of light alone. On examination a NURSING IN OPHTHALMOLOGY 467 cataract appears as a white object filling the pupillary space and preventing the visualization of any of the details of the eye behind the lens. OPERATIONS FOR CATARACT There is no medical treatment to cure cataracts or to prevent their progression. The only effective treatment is surgical, Con- sisting in the removal of the opaque lens. Discission. For congenital cataracts, however, and for Some traumatic ones, an operation is performed in which the capsule of the lens is opened with a thin needle knife and the lens fibers are pierced (discission). This procedure allows the aqueous humor to come into contact with the lens substance, which is then absorbed by the aqueous. This type of operation is successful only in young patients. For all other types of cataracts the eyeball must be opened and the opaque lens extracted. This can be done by two methods, the extracapsular or the intracapsular extraction, both of which are widely used. Extracapsular Operation. In the extracapsular operation the globe is opened by an incision along the limbus over the upper half of the eye. The cornea is then lifted up like the hood of an automobile; the iris is pulled out and a portion excised, the cap- sule of the lens is incised, and as much of the lens substance as possible is expressed from the eye. The globe is closed either by sutures through cornea and sclera, or by the less effective method of sutures in the conjunctival flap. On healing, the posterior cap- sule of the lens, which has been left in the eye, may become opaque and act as a thin curtain before the vision. Discission is then necessary to obtain clear vision. Infracapsular Operation. The newer method, intracapsular extraction, is steadily growing in popularity among ophthalmic surgeons. In this operation the opening and closing of the eye are performed in the same manner as for the extracapsular method, but here the lens is grasped with smooth forceps and extracted within its capsule. The intracapsular technic is a bit more difficult to master than that of the extracapsular operation, but this operation has two important advantages. First, the Cataract can be removed at an earlier stage of maturity, thus shortening the unhappy period while the patient waits in a state of reduced vision for the lens to become completely mature, which is a requirement for the extracapsular operation; second, 468 SURGERY OF THE EYE, EAR, NOSE AND THROAT no discission is necessary after the intracapsular method because in it the posterior capsule of the lens has been removed with the rest of the lens. Trials are being made, at present, of a method in which a sub- stitute lens of plastic material is placed in the eye when the Cataract is removed. If successful, this method will result in greatly improved vision after operation. Postoperative Care. The postoperative care is the same for the extracapsular and intracapsular operations. Until recently both eyes were bandaged at operation and the patient required to be quite flat and still for several days—a most trying time for the patient. Now many surgeons follow a much less rigid and more comfortable postoperative routine. The unoperated eye is leſt uncovered from the start. A pillow is placed beneath the head, and in a few hours the back of the bed is elevated. In two or three days the patient is started up in a chair. The eye is first dressed one and a halſ or two days following operation and each day following this. If everything has gone well the patient is discharged on the seventh or eighth postoperative day, with in- structions to return to the surgeon's office ſor observation at regular intervals. After operation, the eye is moderately inflamed, but this redness gradually clears as healing progresses and the eye is usually white again at the end of a month. Three to four months after operation the eye is usually ready for reſraction and for the prescription of a permanent pair of glasses. However, temporary glasses can be prescribed when the patient leaves the hospital, as long as they understand that the healing process con- tinues for three or ſour months, and the refraction may change until this is complete. A strong spectacle lens is required to take the place of the surgically removed lens of the patient. If the eye is normal in all other respects, normal vision will be regained with properly fitted glasses. Strabismus In this Condition there is inability to direct the two eyes at the same object because of a lack of coordination of the extraocular muscles. The eyes may diverge, converge, or deviate in a vertical direction, and the condition can be congenital or paralytic in nature. When it occurs early in life the patient has no complaint other than the distressing appearance of crossed eyes. In young patients it is important to correct the strabismus at an early stage so as to ensure the proper development of the macular area NURSING IN OPHTHALMOLOGY 469 and, thereſore, vision in the deviating eye. When strabismus occurs after the development of the macular area, double vision immediately results. Some cases of strabismus respond to muscle exercises or to the wearing of glasses, but most patients require surgical treatment. The operations for the correction of strabismus consist in the moving of the faulty muscle or muscles forward or backward ſrom their old attachments to the globe. Unfortunately there is no precise means of estimating how much to move the attach- ment of a muscle in order to correct a given amount of deviation of the eyes, so that several operations may be necessary to cure the squint. Muscle training and exercise, known as Orthoptics, combined with surgery are extremely helpful in the treatment of strabismus. Postoperatively the patients are permitted much more freedom and comfort than after most eye operations. The eyes must be bandaged for a time, but the head can be moved about and the patient is not confined to bed. Neoplasms of the Eye The ophthalmic surgeon is called upon to treat tumors arising both in the eye and in the orbit. Fortunately such neoplasms are not very common. Intraocular tumors arise from the retina, choroid, or iris, or may be metastatic growths from malignant neoplasms located elsewhere in the body. Occasionally, it is pos- sible to remove a small tumor of the iris and save the eye; most intraocular tumors require enucleation. Extraocular tumors may arise from any of the orbital tissues, and may cause exophthal- mos. If benign, these can usually be removed without too much disturbance of the function of the eye. When malignant, exen- teration of the orbital contents is carried out. Roentgen ray and radium therapy must be used with extreme caution, as the lens is particularly susceptible to radiation; a cataract may result from insufficient protection of the lens. NURSING CARE IN OPHTHALMOLOGY Light In most diseases of the eye strong light causes discomfort to the patient (photophobia) and in some instances it may cause great pain. The natural protective reflex, squinting, can result in a squeezing of the lids that may seriously harm the diseased 470 SURGERY OF THE EYE, EAR, NOSE AND THROAT eye. It is obvious, therefore, that the nurse must know of this dan- ger and must take the necessary precautions to protect her patient from excessive light. The patient should always be shielded from strong sunlight as well as from strong artificial light. On the other hand it is important not to keep the room in the depressing gloom of too much darkness. A happy medium can be main- tained. Eyes that are being unbandaged for the first time after operation are particularly sensitive to light, and it is at this time that the compression produced by squinting can do the most damage. It is wise, therefore, to have the room moderately dark during the changing of dressings unless the doctor specifies other- WISé. Drops The nurse may be called upon many times a day to instill drops into the eye. The eye is a sensitive organ and use of the wrong drugs may cause damage. Also, some drugs, regularly used in the treatment of specific eye conditions, are contraindicated in other conditions, and will do irreparable damage if used by mistake. Therefore the importance of being certain that one has the prescribed solution of the proper drug cannot be too strongly emphasized. Technic of Administration. The patient should be in a Com- fortable position. When she is dealing with a bed patient the nurse may stand at either side of the bed and face the patient's head. The dropper is held in the right hand while the fore- finger of the left hand depresses the lower lid as the patient is directed to look upward. A drop is then allowed to fall at the inner aspect of the eye, care being taken not to touch any part of the eye with the dropper. The drop should not be instilled at too great a distance from the eye in order to prevent the shock to the patient that would result from drops hitting the eye force- fully. If the patient is ambulatory, he is seated comfortably in a chair with the head tilted slightly backward on a headrest. The nurse stands in front and a little to one side, using her hands in the manner described for delivering the drop to bed patients. It is quite important when applying pressure to open a lid that none of the pressure reaches the eyeball itself. In children who refuse to open their lids the drop may be deposited at the inner junction of the closed lids with the head bent backward; when they do open their lids the solution will run into the eye. NURSING IN OPHTHALMOLOGY 471 % 2.4% 2%22&_*= ~ S. s§ § * g ºf. g Š SS FIGURE 119. Method of instilling drops into eye. The left index finger is wrapped in a sterile gauze sponge. Care of Solutions and Instruments. Signs of deterioration of Solutions such as sedimentation or change in Color should be looked for by the nurse. If any doubt exists as to the freshness of a solution it should be discarded and a fresh preparation used. It would be ideal to have a separate bottle and dropper for each instillation, but obviously this is impossible because it entails too great waste of time and material. When possible a fresh dropper should be used for each instillation, but since even this is not always practicable the greatest care must be exercised to prevent contamination of the dropper; if it has been contami- nated it must not be returned to the bottle under any circum- stances. The glass pipet with rubber bulb on one end is the usual instrument for instilling drops. The glass portion of this instrument is easily sterilized, whereas the rubber portion under- goes deterioration, so care must be used to draw the solution up into the glass part only. A dropper must never be used for a Second solution unless it has been resterilized. When the nurse is giving drops she must take care not to get any of the solution on her own hands, for from there into her eyes is an easy journey. Everyone who has worked in ophthal- 472 SURGERY OF THE EYE, EAR, NOSE AND THROAT * _^ s.S 2: 34 4 22.22% / Sé. NWN \ºme zºlſ' º FIGURE 120. Technic for irrigating eye. Insert shows irrigation tray containing basin of solution, curved basin, rubber irrigating syringe, cotton and gauze. Note that left index finger of nurse is covered by sterile gauze. mology for any length of time has had the experience of blurred vision and dilated pupils as the result of carelessness in adminis- tering atropine. Irrigations These are indicated in inflammatory conditions of the con- junctiva, as part of the preoperative clean-up and postoperative care, and following the instillation of fluorescein when staining NURSING IN OPHTHALMOLOGY 473 the cornea. The apparatus used in this treatment consists of a simple rubber syringe (a rubber ear syringe is most convenient), or a glass undine; when these are not available an ordinary eye- dropper may be used to deliver the solution into the eye. Cotton or a curved basin is used to catch the solution as it runs from the eye. Boric acid is the most commonly used solution for ir- rigations of the eye. The solution should be warmed, and it should be tested by letting a few drops fall on the wrist to make sure that it is not too hot. Technic. The patient should be either flat in bed, or in a treat- ment chair with the head supported on a headrest. The curved basin or cotton to catch the solution as it leaves the eye is held at the side of the face by the patient or by an assistant. The nurse giving the irrigation stands in front of the patient in order to have full view of what she is doing. The lid margins should be cleansed of foreign matter such as dust, secretion, or Crusts by gentle wiping with cotton. The lids of the eye are held open by the fingers of one hand while the syringe is held in the other hand. The stream of fluid is gently directed onto the eyeball from the nasal portion toward the outer angle, care being taken that none runs over the bridge of the nose into the other eye. The irrigation should be continued until the conjunctival sac is Com- pletely free of secretion and foreign matter. As in the case of the eyedropper, the syringe should not be allowed to touch the eye. At the completion of this treatment the skin of the lids and adjacent areas should be dried with cotton. Hot Compresses Moist heat is used to relieve pain and to increase the circula- tion in inflammatory conditions. Superficial and deep inflamma- tion of the globe, as well as of the lids and orbit, responds well to the application of heat. This is best applied by gauze or cotton compresses large enough to cover the whole orbital area. The patient should be lying in bed, and the pillow and the patient's chest should be covered with a towel to prevent wetting. The skin of the lids should be wiped clean as in irrigations, and a little petrolatum applied to this area to prevent the maceration of the skin that otherwise follows frequent compressing. The gauze or Cotton pads are soaked in a basin of boric acid solution heated on a hot plate at the bedside. The solution is kept be- tween 115 and 120° F.; care must be taken that it does not be- come hot enough to burn the patient. The pads are grasped at TABLE 3. Drugs Commonly Used in Ophthalmology STRENGTH OF NAME MODE OF USE EFFECT REMARKS SOLUTION ANTISEPTIC SOLUTIONS Gantrisin 4% Instill 2 drops Antiseptic Used in external infections of eyes Sodium sulfacetamide 30% Instill 2 drops Antiseptic Used in external infections of eyes (Sulamyd) Aureomycin Instill 2 drops Antiseptic Used in external infections of eyes Terramycin 0.5% Instill 2 drops Antiseptic Used in external infections of eyes OINTMENTS Yellow oxide of mercury 1.2% Apply to lids Mildly antiseptic Used in styes and blepharitis (least effec- tive) Epinephrine bitartrate 2% Apply to eye Dilates Used where strong mydriatic is required Gantrisin 4% Apply to eye Antiseptic Used in external infections of eye Sodium sulfacetamide 10% Apply to eye Antiseptic Used in external infections of eye (Sulamyd) Sulfathiazole 5% Apply to eye Antiseptic Used in external infections of eye Myciduent %% Apply to eye Antiseptic Used in external infections of eye Bacitracin 500 units per gram | Apply to eye Antiseptic Used in external infections of eye Cortisone 1.5% Apply to eye Blocks allergic reactions Used in iritis and uveitis to block inflam- matory reactions while underlying cause is searched for and treated s ANESTHETICS Cocaine hydrochloride 5% Instill 1–3 drops | Anesthetizes cornea; dilates | May damage cornea or cause glaucoma pupil Pontocaine hydrochloride }%% Instill 1–3 drops | Produces anesthesia No harmful side effects Holocaine hydrochloride 1% Instill 1–3 drops | Produces anesthesia No harmful side effects Butyn sulfate 2% Instill 1–3 drops | Produces anesthesia No harmful side effects Procaine 1–2% Injection Produces anesthesia Used for surgery of lids and orbit MYDRIATICS AND CYCLOPLEGICS Atropine sulfate %–3% Instill 1–2 drops | Dilates pupils; paralyzes mus- || The most widely used drug in ophthal- cles of accommodation mology Homatropine hydrobro- 2–5% Instill 1–2 drops | Dilates pupil Used for eye examinations mide Euphthalmine hydro- 5% Instill 1–2 drops | Dilates pupil Short in duration—useful in older pa- chloride tients MIOTICS gº Pilocarpine hydrochloride 1–2% Instill 1–2 drops | Contracts pupil Used in glaucoma Eserine salicylate }4–1% Instill 1–2 drops | Contracts pupil Used in glaucoma OTHER DRUGS Epinephrine 1–1000 Instill 1–2 drops | Dilates pupil; contracts blood | To control hemorrhage vessels Dionin 1–5% Instill 1–2 drops | Relieves pain Smarts immediately on instillation Fluorescein 2% Instill 1 drop Stains corneal abrasion Remove excess by irrigation Antistine %% Instill 1–2 drops | Antihistamine Used in allergic conjunctivitis Cortisone 0.5% Instill 1–2 drops | Blocks allergic reaction Used in inflammations while underlying and 2.5% cause is searched for and removed § 476 SURGERY OF THE EYE, EAR, NOSE AND THROAT each end, twisted to squeeze out the excess fluid, and then smoothed out gently on the closed lids. When the compress cools it is replaced by a hot one every one or two minutes to ensure that constant heat reaches the eye for a period of fifteen or twenty minutes at each treatment. The frequency of the treat- ments is governed by the severity of the condition being treated. The lids are dried and the petrolatum is removed at the end of each treatment. The compress pads and basin are sterilized be. tween treatments and put away for the next treatment of the same patient. Cold Compresses These are helpful in controlling bleeding into the anterior chamber or in edema of the lids (chemosis). They are also recom. mended in the early stages of conjunctivitis to decrease discom- fort and secretion, but should not be used in late or deep-seated infections. Cold compresses are given in the same manner as that described for hot compresses, except that ice is used in the solu. tion in place of heat. Ointments Drugs used in the form of ointments are best applied by means of sterile glass rods to the inner margin of the lower lid of the eye. The patient is instructed to hold the lids closed for five min- utes to allow the ointment to spread and be absorbed. Powders The application of powder to the eye is made simply by dust. ing the powder from a sterile tongue depressor or spatula onto the eye. A drop of Pontocaine beforehand makes the application more comfortable, as the powder acts as a foreign body before it has been dissolved by the tears. Preparation for Operation Before operation the patient should have a general physical examination and such special examinations as are indicated. For most eye operations the eyelashes are cut short and an irrigation is given at bedtime on the night preceding operation. A mild sedative is given to ensure the patient a good night's rest. Most patients are naturally apprehensive at this time and the nurse can do a good deal to allay nervousness. In preparation for major operations a soap solution enema is given in the evening NURSING IN OPHTHALMOLOGY 477 before operation and breakfast is omitted. Tea and toast are given at breakfast time iſ local anesthesia is to be used. For after- noon operations breakfast is given and lunch omitted or re- placed by tea and toast. Post operative Core After operation the patient must be made as comfortable as possible. It is important after most operations that the patient keep his head quite still and that he refrain from any strain such as coughing, vomiting, and the like. The nurse must make it plain that she is there to meet the patient's every need and that he must be completely inactive, allowing everything to be done for him no matter how trivial it may seem. Backache is one of the commonest postoperative complaints, as these patients must lie in one position for a long period. This can be greatly relieved by frequent gentle backrubs. The patient has both eyes covered and therefore feels shut off from his surroundings. Here again the nurse can help by offering frequent reassurance. Occasional patients, particularly those of advanced years, become confused (disoriented) after some time in the utter darkness; nothing less than permitting the opening of the unoperated eye to allow them to reestablish contact with their surroundings will clear this state of confusion. The decision to remove the bandage should be made only by the doctor; he must be notified whenever a patient becomes disoriented. Any severe pain in the eye following operation is also an indication for notifying the doctor. When the patient is sleeping it is the job of the nurse to pre- vent undue movement of the head or touching of the eyes with the hands. In small children enforced restriction by means of a jacket, sheet, or other restraint is necessary to keep the hands away from the eyes. In most cases children's hands can be kept at a safe distance from their eyes by a cuff stiffened with tongue depressors which is fastened around their arms so as to prevent bending at the elbow. SUMMARY Ophthalmologic surgery is undertaken to correct squint, to save vision by replacing a detached retina, by removing a cata- ract, or by relieving the pressure in glaucoma. Injury, inſection, and neoplastic disease may lead to loss of vision and to loss of the eye itself. Apprehension and even psychotic confusion are of 478 SURGERY OF THE EYE, EAR, NOSE AND THROAT common occurrence, but good nursing prevents or minimizes them. VOCABULARY REVIEW conjunctiva hyperopia glaucoma media astigmatism Cataract wveal tract stye strabismus ophthalmoscope chalazion cycloplegic myopia keratitis discission l SUGGESTED READING . Blake, Eugene M.: Glaucoma. Am. J. Nursing, 52:451–452 (April) 1952. 2. Chace, Robert R.: Treatment of Cataract. Am. J. Nursing, 48: 150–152 10. (March) 1948. . Lord, Helen May: Nursing Care in Corncal Ulcer. Am. J. Nursing, 49:378– 380 (June) 1949. . Rones, Benjamin: The Eyes and Vitamins. Am. J. Nursing, 52:728-729 (July) 1952. . Ruedemann, Albert D.: Headaches Caused by Eye Defects. Am. J. Nursing. 52:1093–1094 (September) 1952. . Shaw, Cora L.: Nursing Care of Patients with Cataract. Am. J. Nursing, 48: 153–155 (March) 1948. . Sinescal, Arthur A.: Trachoma. Am. J. Nursing, 52:1508–1510 (Decembel) 1952. . Weaver, Helen E.: The Nurse and Sight Conservation. Am. J. Nursing, 51: 553–555 (September) 1951. ... Weaver, Helen E.: Glaucoma: A Problem for the Public Health Nurse. Pub. Health Nursing, 41.93–94 (February) 1949. Weiss, M. Olga: The Psychological Aspects of Nursing Care for Eye Patients. Am. J. Nursing, 50:218–220 (April) 1950. CHAPTER 42 Nursing in Otolaryngology INTRODUCTION The organs of the upper part of the respiratory tract include the ear, the nose, the paranasal sinuses, the pharnyx, and the larynx. In addition to housing the end-organs of the special senses of hearing, equilibrium, and smell, the upper respiratory tract serves as the entrance to the lungs, and contains the apparatus NURSING IN OTOLARYNGOLOGY 479 Frontal sinuses openings into nose Ethmoidal air cells s--- E-TEF * & tº e º - ſº *** ** Fix. ru membrane # * Ear canal) Middle ear Eustachian tube FIGURE 121. Diagram to show the locations and intercommunications of the nose, the paranasal sinuses, the ears, the pharynx, and the mouth. for producing sound (phonation). The inner surfaces of the components of the tract are lined by a continuous sheet of epithelial cells, which are in some places similar to the squamous cells of the skin, and in other places are mucus-secreting cells. This sheet of cells (membrane) is constantly exposed to the air We breathe, and to all the noxious substances that are found in air, including dust, pollen, bacteria, viruses, and the like. It is not surprising that infections and other diseases of the upper respiratory tract are common. Special instruments, technics, and knowledge are necessary for the proper examination of the tract, and for the diagnosis and the care of its diseases. Largely for these reasons otolaryngology was one of the earliest surgical specialties to be developed. The various parts of the upper respiratory tract are usually spoken of as though they were entities in themselves, and it is true that most of these parts have special characteristics and individual functions; it is important, however, to realize that all are in communication with one another, so that infections spread easily. It is also true that the damage caused by disease in one 480 SURGERY OF THE EYE, EAR, NOSE AND THROAT FIGURE 122. The use of the head mirror and of the laryngoscopic mirror en ables the examiner to see the vocal cords. component of the tract may cause changes in function in other Components. METHODS OF EXAMINING THE UPPER RESPIRATORY TRACT The otolaryngologist must learn to peer through tiny aper- tures, into dark cavities, and around corners. One of the most useful devices in his armamentarium is the head mirror. This is a curved mirror with a peep-hole through its center; it is worn on the forehead of the examiner so that he may look with one eye through the peep-hole; at the same time the mirror reflects a focused beam of light at the patient from a source of light placed to one side of the patient's head. Using the head mirror, the examiner looks into the nostrils, which he spreads with a nasal speculum, and into the pharynx while he holds the back of the tongue down with a tongue depressor. By means of a small mirror held at a 45 degree angle in the pharynx over the epi- glottis, it is possible to see down into the larynx and to observe the action of the vocal cords. Modern ingenuity has supple- mented these simple tools with electrically illuminated tubes, some of which are equipped with magnifying lenses; the otoscope NURSING IN OTOLARYNGOLOGY 481 is used to visualize the ear drum (tympanic membrane); the pharyngoscope enables the examiner to see the posterior naso- pharynx, including the orifices of the eustachian tubes; the laryn- goscope, a short form of bronchoscope, can be passed directly into the larynx. Transillumination. Information as to the condition of the para- nasal sinuses, specifically the maxillary and frontal sinuses, may be gained by transillumination. In this examination a light is placed in the mouth of the patient, the lips are closed, and the room is darkened. Normal sinuses, because they contain air, transmit the light well, whereas diseased sinuses remain dark. Properly taken roentgenograms furnish the same information more reliably, and show the condition of the ethmoid and sphenoid sinuses, as well as of the mastoid cells. Tests of Hearing and Equilibrium. It is also the function of the otolaryngologist to examine the patient's hearing and sense of equilibrium. Audiometric Tests. Much can be learned by the use of a tuning fork, but more accurate determination of the exact amount of hearing in each ear can be made by the use of the audiometer, an electronic device which can produce pure tones of any de- sired pitch or intensity. During the examination the hearing of the ear not undergoing the test is masked by directing into it a buzzing sound, so as to prevent the crossing over to it of sound from the other side through conduction by the bones of the skull. Caloric and Spinning Tests. The function of the vestibular apparatus (that is, to maintain equilibrium) is tested by the caloric test and by spinning the patient in a tilting chair. In the caloric test ice water is dropped on the ear drum, a violent stimulus which, in a normal subject, immediately produces ver. tigo. Anyone who has, as a child, spun in an untwisting rope swing can appreciate the tilting chair test. In this manner the fluid in the semicircular canals is set into motion and the re- sponse of the patient is observed. THE NOSE AND THE PARANASAL SINUSES Anatomy and Physiology. The external nose consists of bone and cartilage covered with muscles and skin. Internally the nasal Septum, Composed of Cartilage and bone, divides the nose into two cavities. On the lateral wall of each nasal cavity are three elongated, shell-like bones covered with thick, vascular mucous 482 SURGERY OF THE EYE, EAR, NOSE AND THROAT membrane, called the turbinates. The space between the inferior turbinate and middle turbinate is known as the middle meatus. It is into this region that the nasolacrimal duct opens. The su- perior meatus is just above the middle turbinate. The middle and superior meatuses are of clinical importance because it is into these two spaces that the nasal sinuses drain. The paranasal sinuses are eight in number—on each side, there are the frontal, maxillary, sphenoid, and ethmoid. They are nor- mally filled with air and lined with thin mucous membrane. As in the nose, the outer layer of this membrane is covered with ciliated epithelium. All the sinuses communicate with the nose through their various openings or ostia. The frontal sinuses lie in the frontal bone, one above each eye. They vary greatly in size or may be absent. Each frontal sinus drains into the middle meatus on the same side. The maxillary sinuses lie in the Superior maxillary bone in each cheek and they also open into the middle meatus. The ethmoid sinuses are a group of tiny cavities which lie on each side of the nose between the middle and superior turbinates and the orbit. They communicate with both the mid- dle and superior meatuses. The sphenoid sinus is also paired, each one lying in the sphenoidal bone and separated from its fellow by a bony partition. This sinus drains into the superior IſleatuS. The functions of the nose are respiratory, olfactory, and phona- tory; of these the respiratory function is by far the most im: portant. The nose warms, moistens, and filters the inspired air before it enters the lungs. As air is drawn through the nose, its temperature is raised or lowered as required to approximate body temperature. The nasal mucous membrane is covered with a thin layer of mucus; some of this moisture is taken up by the inspired air. Possibly an even more important function of the mucous layer is to catch small dust particles, bacteria, and the like, on its surface. The layer of mucus is not stationary, but is kept in constant motion by the action of the cilia. This whip- like action of the cilia causes the mucus to move toward the throat. Thus, entrapped particles are carried to the throat and swallowed, rather than drawn into the lungs. The ends of the olfactory nerve are located in the upper one third of the nose. It is by means of this nerve that we appreciate flavors. The nose and sinuses together with the throat and chest act as resonant chambers and give quality (timbre) to the voice. NURSING IN OTOLARY NGOLOGY 483 Disturbances of the Nose FURUNCLE The vestibule of the nose is lined with skin and with short hairs called vibrissae. Not uncommonly one or more of these hair follicles become infected, giving rise to a furuncle. These furuncles should never be squeezed or picked as this procedure may cause the infection to spread along the veins of the nose to the venous sinuses of the brain. Treatment. It is, however, safe to apply 2 per cent yellow oxide of mercury ointment to the inflamed area. The more severe infections should be treated with hot compresses. Such pro- cedures will usually cause the furuncle to become localized and eventually to rupture spontaneously. Penicillin is administered 1I] S62F1OUIS CaSeS. EPISTAXIS Nasal hemorrhage is a common ailment. It may result from injury to the nose, operation, ulceration, hemophilia, nose-pick- ing in children, or hypertension. Considerable blood may be lost. Fortunately, the commonest site of the bleeding is the an- terior portion of the septum where there is a rich anastomosis of blood vessels. Treatment. Often the bleeding can be controlled by simply pressing the nostrils between the fingers for a few minutes, or in- troducing into the nostril a small pledget of Cotton saturated with adrenalin. The patient should be placed in the semire- Cumbent position. If the bleeding is severe and the patient is restless, he should be given morphine. Electrocautery. Bleeding is apt to recur unless the area is cauter- ized. Under direct vision, a small cotton pledget moistened with a few drops of 10 per cent cocaine solution containing adrenalin is placed over the bleeding point. In the majority of cases this stops the hemorrhage and also anesthetizes the area, which is then touched with a silver nitrate stick or coagulated with elec- trocautery. Profuse Hemorrhage. Occasionally the hemorrhage is too pro- fuse to be controlled by these methods, or it may be from higher in the nose. In this event the nose must be packed with 9% inch gauze which has been well saturated with petrolatum. This packing should not remain in the nose for longer than twenty- 484 SURGERY OF THE EYE, EAR, NOSE AND THROAT four hours; if left for a longer period of time, it becomes foul and may give rise to an infection of the sinuses. FOREIGN BODIES Children are prone to introduce small foreign bodies, such as beads, peas, beans, and so on, into the nose. Beans and peas may even sprout, but any foreign body will cause swelling of the mucous membrane of the side where it is located, with resultant nasal obstruction. There is also a discharge (often purulent) ſrom the nostril. Removal. Removal can usually be accomplished after the ap- plication of 10 per cent cocaine solution with adrenalin on a cotton pledget. Occasionally a general anesthetic has to be ad- ministered. FRACTURES Fractures of the nose commonly involve the nasal bones and the septum; occasionally the septum alone is fractured. These structures may be displaced laterally or anteroposteriorly, or there may be a combination of the two. After injury there is usually a brisk nosebleed, which subsides spontaneously within a short time. Swelling of the soft tissues soon follows. Often the external deſormity may be noted on simple inspection, or actual crepitus may be felt. On examination of the interior of the nose, the septum is seen to be deflected to one side or the other. An x-ray film will show a crack in the nasal bones and any displace- ment of the fragments. Treatment. If there is no displacement of the bone and iſ the deſlection of the septum is minimal, no treatment is required. If, however, the nasal bones are depressed or the septum is seri- ously displaced, these structures should be replaced in their nor. mal position. This is done by manipulation under anesthesia. Packing is not required after the fracture has been reduced as the bones and the septum tend to stay in position once the proper alignment has been made. DEVIATION OF THE NASAL SEPTUM Deviation of the nasal septum is either traumatic or develop. mental in origin. An untreated fracture of the nose may result in a permanent deflection of the septum. In other instances, be: cause of some unknown factor in the growth of the nose, the sep- tum becomes thickened or is displaced into one nostril. Sufficient NURSING IN OTOLARYNGOLOGY 485 septal deflection causes respiratory obstruction. Often the patient has repeated colds and complains that a cold persists for several weeks; a patient with a severe septal deflection will give a history of repeated attacks of acute sinusitis on the affected side, due to blocking of normal drainage from the sinuses. Submucous Resection. Operative treatment is indicated if the deflection is obstructing ventilation or drainage. The operation to correct a deviated septum is called submucous resection; it is performed under local anesthesia. The patient is allowed to have breakfast. He is given 0.2 gm. of phenobarbital half an hour before the scheduled time for operation for the purpose of coun- teracting any toxic effects of cocaine. The patient may be seated in an ordinary office chair or, if the operator prefers to stand, the patient may be placed on an operating table, one end of which is elevated to serve as a back rest. The septum is anes- thetized by the application of cotton tampons moistened with 20 per cent cocaine solution containing adrenalin. These tam- pons should have the excess cocaine solution squeezed from them beſore insertion in the nose, thus preventing a large amount of the cocaine from being swallowed and lessening the possibility of overdosage. The cartilage and bone of the nasal septum are removed from beneath the mucous membrane. When this is done completely the remaining septum (largely mucous mem- brane) should be in the midline. A petrolatum gauze pack is inserted into each nostril to hold the flaps of mucous membrane together and to control bleeding. These packs should be removed early the next day. Nursing Care. The patient should remain in bed until after the packs are removed. For the first three or ſour hours he is placed in semi-Fowler's position and ice compresses are applied to the nose. There is remarkably little postoperative pain and what little discomfort there is may be readily controlled with codeine and aspirin. The patient may be placed on whatever diet is desired. These patients should be watched carefully for any evidence of excessive bleeding. Disecises of the Porcinciscal Sinuses SINUSITIS Infection of the lining membrane of the sinuses may be acute or chronic. Any sinuses may be involved, but the ethmoid and the maxillary are the ones most commonly affected. The common Cold is the usual forerunner of acute sinusitis; chronic sinusitis 486 SURGERY OF THE EYE, EAR, NOSE AND THROAT results from the neglect of acute sinusitis. A deviated nasal septum or swelling of the mucous membrane due to allergy (al- lergic rhinitis) may interfere with the drainage of an acutely in- fected sinus to such a degree that a chronic infection results. In- fection of the roots of the upper bicuspid and molar teeth at times causes chronic infection of the maxillary sinuses as the roots of these teeth lie close to the floor of the sinus. An infected sinus may be a focus of infection in such diseases as bronchitis, bronchial asthma, bronchiectasis, nephritis, arthri- tis, and certain diseases of the eye. INFECTION OF THE ETHMOID SINUS Acute Ethmoiditis. In nearly every severe head cold there is an accompanying ethmoiditis. The patient complains of a stuffy sensation in the nose and there is profuse mucopurulent nasal discharge. Often there is headache between the eyes and pain on movement of the eyes. There is edema of the nasal mucous mem- brane and purulent discharge above and below the middle turbinate. Treatment. Reestablishment of drainage may be accomplished by the local application of agents such as Cocaine, ephedrine, neosynephrine, Privine, and Paredrine which cause shrinking of the congested mucous membrane. Chronic Ethmoid Sinusiris. Here the symptoms are those of per- sistent nasal obstruction on the involved side and nasal dis- charge. Headache is frequently not present, but the patient may complain of an impaired sense of smell. On examination a dis- charge is seen above or below the middle turbinate, depending on whether the posterior or anterior ethmoid sinuses are in- volved. Frequently polyps are seen in these regions. A polyp is an edematous overgrowth of the chronically infected mucous membrane. In appearance it closely resembles a peeled grape. Polyps vary greatly in size and number, and may grow to fill the entire nostril. Nasal allergy and neoplasm of the sinuses cause polyps as well as infection. Treatment. Occasionally a mild chronic ethmoid infection responds to conservative treatment, but the majority of the cases require operation. The preparation of the patient is the same as for submucous resection (p. 485). The operation is performed under local anesthesia. The middle turbinate is removed and the ethmoid cells thus exposed are removed by biting them away with an ethmoid rongeur. If the patient has a deviated nasal NURSING IN OTOLARYNGOLOGY 487 septum this should be straightened. The nose is packed with petrolatum gauze. The after-care of the patient is similar to that given after submucous resection. INFECTION OF THE SPHENOID SINUS This condition often accompanies an infection of the cor- responding posterior ethmoid sinus, and may be either acute or chronic. Often the only symptoms of either type of infection are nasal obstruction and discharge from the nose. Because of the position of the sinus the discharge is frequently postnasal (ac- cumulating in the throat). If headache is present there is noth- ing typical in its location; headache in the occipital region, how- ever, is suggestive of a sphenoidal infection. There is discharge above the posterior end of the middle turbinate. An x-ray exam- ination may show clouding of the sinus. Treatment of Acufe Form. The milder acute infections usually respond to daily shrinking of the nasal mucous membrane in the region of the sphenoid orifice, but the more severe acute infec- tions sometimes require irrigation of the sphenoid through the natural Ostium. Operation for Chronic Form. If a chronic sphenoid infection is present, the posterior end of the middle turbinate is removed under local anesthesia and the sinus orifice is enlarged with sphenoid rongeurs. The interior of the sinus should never be curetted because of possible injury to the optic nerve or carotid artery. Many operators routinely enlarge the sphenoid orifice at the time of the performance of an operation on the ethmoid sinuses. The postoperative care consists primarily of irrigations of the sinus through the enlarged ostium. INFECTION OF THE MAXILLARY SINUS Acute Form. The patient who has acute maxillary sinusitis complains of nasal obstruction and discharge; in addition, head- ache above the eyes (frontal headache) is commonly present. Often the patient complains of pain in the face and in the upper teeth on the involved side, or simply of a fulness in this region. There is discharge under the middle turbinate, and the sinus does not transilluminate clearly. Roentgenograms are much more accurate than transillumination in diagnosing maxillary sinusitis, and may show diffuse clouding or a level of fluid (that is, pus) in the sinus. Treatment. At first the treatment Consists in efforts to reduce 488 SURGERY OF THE EYE, EAR, NOSE AND THROAT FIGURE 123. Establishing drainage of an acutely inflamed maxillary sinus by introducing a trocar into the sinus. the swelling of the nasal mucous membrane in order to promote drainage. Codeine with aspirin is given every four hours if there is much discomfort. If definite improvement is not shown in forty-eight hours, the sinus should be punctured and the pus washed out. To do this a cotton-tipped nasal applicator mois- tened with a few drops each of 20 per cent cocaine solution and l in 1000 adrenalin is introduced beneath the anterior end of the inſerior turbinate and is allowed to remain about twenty min- utes. Then a curved trocar is put through the thin bone under the inſerior turbinate. The patient leans forward and holds a basin under his chin. Warm sterile normal saline is gently forced through the trocar and comes out through the natural ostium, carrying pus with it. If desired, a culture is taken. These irriga- tions should be carried out every day or every other day until the washings return clear. Chronic Form. Chronic maxillary sinusitis is characterized by long standing nasal discharge and obstruction. There may be NURSING IN OTOLARYNGOLOGY 489 frontal headache, but, unless there is an acute infection, pain in the face and upper teeth is not present. The lining membrane becomes thickened and may contain microscopic abscesses. Dis- charge or polyps, or both, are present in the middle meatus. The sinus is dark on transillumination and cloudy on x-ray examina- tion. Treatment. Occasionally three or four punctures and irriga- tions of the sinus will clear up the infection if polyps are not present, but the greater number of patients will require a radical antrum (Caldwell-Luc) operation. TECHNIC OF CALDwell-LUC OPERATION. This operation is best performed under general anesthesia. The preoperative prepara- tion is the same as that for any patient undergoing general anes- thesia. The head of the operating table should be lowered slightly to prevent aspiration of blood and mucus. A postnasal pack is inserted to prevent blood from draining into the pharynx. An incision about 1% inches long is made in the mouth along the upper gum above the canine teeth; the periosteum is elevated with a periosteal elevator and the bone exposed. With a perfora- tor an opening is made into the maxillary sinus and the opening is enlarged with bone forceps. The lining mucous membrane is completely removed from the sinus with forceps. An opening is then made into the sinus beneath the inferior turbinate. A small petrolatum gauze pack is placed in the antrum and one end brought out through the opening under the inferior tur- binate. The incision over the canine fossa is sutured. Nursing Care. The patient is placed in bed face down with a pillow under his chest until the swallowing reflex returns. He may then be placed in semi-Fowler's position. Ice compresses are applied to the face for five or six hours to help prevent swelling. Morphine may be administered every four hours if necessary to control pain. The patient is given a liquid diet for two or three days, and is watched carefully for signs of excessive bleeding. The pack is removed the day after operation. Postoperative care con- sists of irrigations through the opening into the sinus under the inferior turbinate until the washings return clear. INFECTION OF THE FRONTAL SINUS Acute Form. The cause of acute frontal sinusitis is identical with that of acute ethmoid or maxillary sinusitis. Frontal head- ache and pain above the eye are nearly always present. The pa- tient usually awakens in the morning with no discomfort, but 490 SURGERY OF THE EYE, EAR, NOSE AND THROAT after he has been up for several hours the headache and pain appear and are extremely severe. Examination reveals the same findings as in acute ethmoiditis. In addition the anterior wall of the frontal sinus is tender on light percussion, a finding charac- teristic of the disease. The involved sinus does not transilluminate clearly and x-ray examination shows cloudiness or a fluid level in the sinus. Treatment. Treatment consists in shrinking the nasal mem. brane in the region of the nasofrontal duct, under the anterior end of the middle turbinate. The application of moist or dry heat to the involved sinus is of benefit. Codeine and aspirin should be given for relief of pain. If after several days of this treatment improvement does not take place, the sinus should be irrigated. This is accomplished by introducing a curved frontal sinus cannula into the sinus through the nasofrontal duct after cocainization of this area. The sinus is gently irrigated with warm sterile normal salt solution, a small rubber bulb being attached to the cannula. Sometimes the anterior third of the middle turbinate must be removed before this procedure can be carried OUlt. TREPHINING. In obstinate cases the author prefers trephine of the sinus to irrigation. This is accomplished under general anes thesia. The eyebrow is shaved off on the involved side. A pack is placed in the nasopharynx to prevent aspiration of pus. Cotton pads moistened with warm normal salt solution are placed over the eyes. An incision about I inch long is made through the inner third of the eyebrow. With a perforator a small opening is made through the anterior bony wall of the sinus. At this point in the operation the mucous membrane of the sinus often bulges into the wound, and is incised; the pus is gently removed with suc. tion. A short length of soft rubber tubing is placed through the opening into the sinus and anchored to the skin edges with suture. The wound is left wide open and dressings are applied. The relief of pain and headache is most dramatic. On the second day after operation the drain is removed and the sinus irrigated through the wound with warm sterile salt solution. These ir. rigations are carried out daily until there is no pus in the wash. ings. The wound is then allowed to heal. Chronic Form. Chronic frontal sinusitis may give rise to osteo. myelitis of the frontal bone, brain abscess, extradural abscess, or meningitis. Because of the danger of these complications it is the NURSING IN OTOLARYNGOLOGY 491 most serious of the chronic sinus infections. The symptoms are frontal headache and a purulent nasal discharge. Rarely is there tenderness over the involved sinus unless there is a Superimposed acute inſection. As in acute frontal sinusitis, a discharge is visible under the anterior end of the middle turbinate, and nasal polyps may be seen in this area. There is frequently an associated chronic inſection of the ethmoids. The infected sinus tranillumi- nates poorly and an x-ray film shows clouding. Treatment. Any treatment other than operative is of no avail. If the ethmoid sinuses are infected they, too, should be operated upon. TECHNIQUE OF OPERATION. The radical operation for chronic ſrontal sinusitis is performed with the patient under general anes- thesia. The preoperative preparations are identical with those for trephining (p. 490). An incision is made through the eyebrow for almost its entire length. The bone of the entire anterior wall and part of the floor of the sinus are removed with rongeurs. The entire mucous membrane lining of the sinus is removed with a curette. The resulting bony cavity is carefully inspected for any areas of infection (osteomyelitis); if any are found, all diseased bone is removed. The nasofrontal duct is then enlarged with a rasp. A piece of soft rubber tubing is placed in the sinus at the inner angle of the wound and sutured to the skin edges. The flaps of periosteum, muscle, and subcutaneous tissue are closed with catgut; the skin edges are closed with fine silkworm gut. The drain is removed on the second day after operation. Postopera- tive care consists of irrigations of the sinus through the enlarged nasofrontal duct. CHEMOTHERAPY AND ANTIBIOTICS IN SINUSITIS The systemic effects upon the patient with sinusitis are varia- ble: some patients are systematically ill, with fever, anorexia, and malaise, whereas others complain only of the local symptoms. In recent years the treatment of acute sinusitis, and to a less extent chronic sinusitis, has been revolutionized by the introduc- tion of the various antibiotics. In the acute cases, the subjective symptoms are usually reduced both in severity and duration. It is also most significant that the frequency of complications has been tremendously reduced. In some cases of chronic sinusitis, the administration of antibiotics has resulted in improvement to such a degree that operation has been found unnecessary. In an 492 SURGERY OF THE EYE, EAR, NOSE AND THROAT even greater number of cases antibiotics given preoperatively and postoperatively have greatly reduced the period of con- valescence, and the incidence of complications due to a spread- ing of the infection. Instead of trying one antibiotic after another in a hit or miss manner, one should get a culture of the discharge as it comes from the sinus. After the offending organism or organisms are isolated, it is a relatively simple laboratory procedure to deter- mine the sensitivity of the organisms to the various antibiotics. Naturally, the antibiotic chosen is the one to which the organisms are most sensitive. NEOPLASTIC DISEASE OF THE NOSE AND SINUSES Many varieties of neoplasms occur in the nose and accessory sinuses, but the commonest tumor is carcinoma. Here, as else- where, the onset is insidious and painless; the first Complaints of the patient are either the result of infection which follows ob- struction caused by the neoplasm, or are due to metastases in the lymph nodes of the neck, in the mediastinum, or in the bones of the skull. By the time symptoms direct attention to the tumor it has usually spread beyond the local limits of its origin, so that surgical treatment is futile; in some types of carcinoma good re- sults follow radiation therapy, but in general the prognosis is unfavorable. THE PHARYNX AND THE LARYNX Anatomy and Physiology. The pharynx is that part of the upper respiratory tract which is continuous with the posterior portions of the nose and mouth. The inferior portion of the pharynx is continuous with the larynx and esophagus; the pharynx is thus common to both the respiratory and the ali- mentary tracts. The lining membrane of the pharynx is epithelial, and in the upper portion (nasopharynx) the surface cells are ciliated. Beneath the epithelial surface are many mucous glands and much lymphoid tissue. There is usually a mass of lymphoid tissue located along the roof and posterior wall of the pharynx On each side; these masses constitute the adenoids. There are also several sets of muscles in the pharyngeal wall which are neces. sary for Swallowing and aid in phonation. On the upper lateral wall of the pharynx on each side is found the orifice of the eustachian tube, a duct which leads directly into the cavity of the middle ear. In the lower pharynx, lateral and posterior to NURSING IN OTOLARY NGOLOGY 493 the base of the tongue, are large, oval masses of lymphoid tissue; these are the tonsils. The larynx is a semirigid tube joining the lower pharynx and the upper trachea. It is lined with the characteristic mucous membrane of the respiratory tract and owes its rigidity to the support given by the hyoid bone, and the arytenoid, Cricoid, and thyroid cartilages. The upper end of the larynx (glottis) is im- mediately behind the tongue, and is guarded by a trapdoor-like structure, the epiglottis, which covers the opening during swal- lowing, thus preventing the entrance of food, fluid, or other ſoreign material into the larynx. Within the larynx are the vocal cords, two ſolds of fibrous tissue covered with Squamous epithelium, which project into the lumen. The position of the cords, the vibration of which produces the sound of the voice, is determined by the action of the intrinsic muscles of the larynx. These muscles, and also those which control the position and movements of the epiglottis, are activated by the tenth cranial nerves. Adenoids The commonest disorder of the nasopharynx is chronic infec- tion and hypertrophy of the adenoid (lymphatic) tissue. Follow- ing the repeated colds of infancy and childhood, the adenoids may become large enough to obstruct the opening between the posterior nose and the nasopharynx, resulting in habitual mouth breathing. Hypertrophy of the adenoid tissue, further- more, may cause blocking of the orifices of the eustachian tubes, the chief cause of middle ear infection (otitis media) and deaf- ness in children; it is also the important factor in aerotitis, a common complaint among aviators. Diagnosis of infected, hyper- trophied adenoids is readily made upon inspection of the naso- pharynx by means of the nasopharyngoscope. Treatment. Treatment consists in the surgical removal of the adenoid tissue, or in its destruction by radiation. The surgical procedure (adenoidectomy) is usually combined with removal of the tonsils (tonsillectomy) and is described with that operation. It is impossible to remove all the lymphoid tissue surgically, how- ever, and any remnants may hypertrophy to cause recurrence of the condition. The results of irradiation are more satisfactory; for this purpose the brief application of radium or its gaseous emanation (radon) is used. The radium applicator is introduced gently through the inferior meatus of each nostril of the re- 494 SURGERY OF THE EYE, EAR, NOSE AND THROAT cumbent patient. The exposure is brief and must be carefully timed to secure adequate radiation without causing a burn from overexposure. Tonsillifis Acute Form. The symptoms of acute tonsillitis are sore throat, pain and difficulty in swallowing, and malaise. Fever is usually present. The commonest cause of the infection is the strepto- coccus, but the possibility of diphtheria and of Vincent's angina must be considered. Scarlet fever also begins with a sore throat, and it is a good general rule that patients with acute tonsillitis be isolated promptly. The tonsils are swollen and red, and often there are patches of white or yellowish exudate on the surface. The lymph nodes of the neck are enlarged and tender. Smears and cultures of the tonsillar exudate must be made in Order to identify the causative bacteria. Treatment. Treatment consists in local measures Combined with systemic therapy to combat the infection. The sulfonamides and penicillin are effective. Rest in bed, liquid or soft diet, ade- quate fluids, and codeine and aspirin are prescribed. Mild cases respond to this treatment; severe cases should be treated with sulfadiazine or penicillin ( or both), the former by mouth and the latter intramuscularly. TONSILLECTOMY Indications. There are several reasons for removing the tonsils. Repeated attacks of acute tonsillitis lead to the persistent pres- ence of pathogenic bacteria, causing low-grade chronic tonsillitis; this condition seems to cause further acute flare-ups, and also acts as a focus of infection which may have harmful effects in other parts of the body. In addition to chronic tonsillitis, other indications for tonsillectomy are the presence of persistently en- larged cervical lymph nodes, repeated attacks of otitis media, and the occurrence of such systemic diseases as infectious arthri- tis, rheumatic fever, or chronic nephritis. Technic. Tonsillectomy and adenoidectomy are usually com- bined into one procedure; T. and A., as it is familiarly called, is possibly the most frequently performed operation. Tonsillectomy is readily carried out under either local or general anesthesia, but the combined T. and A. requires a general anesthesia. At least six weeks should elapse between the most recent acute infection of the upper respiratory tract and the operation. During the NURSING IN OTOLARYNGOLOGY 495 2– & Tongue %\\ #T-Post. wall of pharynx | || %{i}>Roof of mouth Tonsil FIGURE 124. Tonsillectomy. operation the operating table should be inclined about 15 de- grees, with the patient's head lower than his feet, so as to reduce to a minimum the possible aspiration of blood or tonsillar debris. Adenoid tissue is scraped from the nasopharynx by means of a Curette, and bleeding is checked by packing with gauze. Each tonsil is then grasped and dissected free with scapel and scissors. Catgut sutures are used to control bleeding from the tonsillar fossae. Constant suction is employed to keep the throat dry, thus preventing aspiration. Nursing Care. The postoperative care is like that given patients after any general anesthesia (p. 81). On return from the operat- ing room the patient is placed face downward, with a pillow under his chest until the swallowing reflex returns. While he is in this position there is no danger of aspiration because the secretions will drain out of the mouth. An emesis basin and a generous supply of gauze or paper tissue is provided for the ex- pectoration of blood, mucus, and saliva. An ice collar is applied 496 SURGERY OF THE EYE, EAR, NOSE AND THROAT immediately. As soon as the patient is conscious he is placed in Fowler's position. Bleeding is the chief complication; when the blood is expec- torated it is bright red, but when it is swallowed and then vomited the mixing with the gastric juice produces a reddish brown color. If the patient is not fully awake or is dozing when the bleeding starts he may be observed to swallow frequently. A steady increase in pulse rate or the frequent expectoration of bright red blood should be reported to the surgeon. Water and cracked ice are given as soon as nausea ceases. Codeine is usually given the first day. On the second day, gargles of normal salt solution or aspirin in suspension are helpful to relieve discomfort. If aspirin in chewing gum is given about one half hour beſore mealtime, a semi-liquid diet can be taken with little discomfort. Orange, grapefruit, and lemon juice are ex- cluded from the diet. Fluids should be forced to three liters daily and must be offered regularly and the patient encouraged to drink. Adults are usually discharged from the hospital on the third or fourth day after operation, but children commonly leave the hos- pital on the second day. The adult is instructed to be a con- valescent for at least one week, and should gargle twice or three times daily, drink three liters of fluids daily, and refrain ſrom strenuous exercise. Perifonsillor Abscess This condition, also called quinsy, is a Complication of the spread of infection from the tonsil into the adjoining pharyngeal wall with abscess formation. The symptoms are the same as those of a severe tonsillitis, usually with localization to the affected side. Swelling of the pharynx is readily seen, and fluctuation can be felt. Treatment. The treatment is incision and drainage, release of the pus causing almost instantaneous relief of pain. Great care must be used to prevent aspiration of any of the pus or blood. Laryngitis Inflammation of the larynx is a Common Complication of in- fections of the upper respiratory tract. The consequent edema and thickening of the mucous membrane and vocal cords result in hoarseness and Cough; there may be actual loss of voice and, in severe cases, respiratory obstruction which is due in part to spasm NURSING IN OTOLARYNGOLOGY 497 Č }% Bronchoscope Bronchoscope in trached FIGURE 125. Bronchoscopy. of the laryngeal muscles. One form of laryngitis occurring in infancy and childhood is called croup. Diphtheria produces the most serious variety of laryngitis, as the inflammatory exudate (diphtheritic membrane) may produce mechanical obstruction to the passage of air. In such a case, in addition to treating the in- fection, a breathing tube is inserted from the mouth into the trachea to prevent asphyxiation; this is called intubation. The tube is retained until the obstruction subsides. Less severe forms of laryngitis respond well to inhalation of steam generated by a Croup kettle. A chronic type of laryngitis occurs after repeated upper respira- tory tract infections, or after prolonged abuse of the voice; actual thickening of the vocal cords results, but the symptoms disappear upon removal of the cause and a proper period of rest. Neoplcisms of the Pharynx and Lorynx Both benign and malignant tumors arise in the nasopharynx, more often in adults than in children; malignant tumors are the 498 SURGERY OF THE EYE, EAR, NOSE AND THROAT more frequent. The same symptoms are produced by these as are produced by hypertrophy of the adenoids (p. 493); in the later stages nosebleed is common. Impairment of hearing usually fol- lows, and metastasis to the cervical lymph nodes is the rule. Cure seldom follows surgery, but irradiation is more successful. Tonsil- lar tumors also are usually malignant and are treated more suc- cessfully by radiation than by surgery. Biopsy, however, should be routinely performed in order to establish the correct diagnosis. The prognosis is more favorable in laryngeal tumors. Benign epithelial papilloma, a tassel-like or cauliflower-like growth, is a common lesion; it causes persistent hoarseness, and is perma- nently cured by surgical removal, performed through a laryn- goSCOpe. Cancer of the larynx is also a common disease; since it gives rise to the early symptom of hoarseness, it is often curable. The larynx is removed (laryngectomy), necessitating a permanent tracheotomy. The voice is lost, but an artificial larynx is avail- able, by means of which the patient can make himself heard and understood. TRACHEOTOMY The purpose of this operation is to produce an opening through the neck into the trachea for the purpose of respiration. Permanent tracheotomies are necessary after laryngectomy and in patients having constriction of the upper larynx resulting from disease or injury. Tracheotomy is often an emergency procedure as well, in order to prevent asphyxiation when sudden obstruc- tion of the larynx occurs, as in severe infections of the upper neck (e.g., Ludwig's angina), angioneurotic edema, or hemor- rhage. Since death from asphyxia occurs in a few minutes, a sterile tracheotomy set must be available in every hospital ward in which there are patients who have diphtheria, other laryngeal disease, serious infection of the neck, or recent operations about the neck. Technic. The operation may be perſormed swiftly and easily. Procaine infiltration of the skin is the only anesthesia necessary, and even that is not needed for a patient who is in extremis. A short vertical incision is made in the skin of the lower neck directly over the trachea. The deep fascia is incised and the neck muscles are retracted to either side, exposing the trachea. If care is taken to stay below the isthmus of the thyroid gland, prac- tically no bleeding is encountered. The trachea itself is then NURSING IN OTOLARYNGOLOGY 499 r ū º sº S \\ ſ § | º \ t N FIGURE 126. Tracheotomy set. This tray of instruments is dry-sterilized and kept on the ward for emergency use. Each tracheotomy tube (a) consists of three parts made to fit each other: outer or guard tube, inner tube, and obturator. incised and three cartilaginous rings are divided. Air rushes in and out as soon as the trachea is opened, and the patient's relief is immediate. A tracheotomy tube of the proper size is then in- serted and strapped to the neck. Fortunately the tracheal mucosa at this level is quite insensitive, so that the tube is well tolerated. The wound about the tube is loosely packed with gauze, and no attempt is made to close it as there is always bacterial contamina- tion from the open trachea. Wounds of the trachea, either operative or traumatic, have a tendency to heal rapidly; it is necessary, therefore, to keep a tube 500 SURGERY OF THE EYE, EAR, NOSE AND THROAT FIGURE 127. Tracheotomy. in the trachea constantly if the surgeon wants the tracheotomy to be permanent. When, on the other hand, the tracheotomy is no longer needed, the tube is removed; complete healing occurs in two to three weeks. Tracheotomy tubes are made of noncorrosive metal, and in various sizes. The outer or guard tube should fit the trachea snugly. The inner tube fits exactly into the guard tube, and may be removed at will by the nurse or the patient for cleaning and removing obstructing clots of mucus. The guard tube should be changed or adjusted only by the surgeon, however, since it is often difficult to replace. Nursing Care. A patient with a newly inserted tracheotomy tube is most conveniently cared for in a private room. The con- stant attention of a nurse is required for at least a few days, often much longer, depending upon the case. The patient is voiceless, and so cannot call for help or, if a baby, cry aloud. Fluids are given soon after operation; diet as tolerated may be administered the following day. Antibiotic agents, usually penicil- lin and streptomycin, are given routinely for the first few days. NURSING IN OTOLARYNGOLOGY 501 The room should be humidified in cool weather, but the tem- perature should be kept at 70° F. Opiates and atropine must not be given and the surgeon often writes an order to this effect. Opiates would decrease the cough reflex and atropine would dry up the se...retions; both are contraindicated. Equipment. The complete care of the patient is accomplished in the safest and easiest manner when the room is equipped with all the necessary facilities. Articles for this purpose include a suc- tion apparatus to which is attached a rubber catheter that fits the tracheotomy tube, a bottle filled with sterile salt solution in which the catheter is rinsed, a jar of sterile sponges, a sterile ſorceps in 1 per cent lysol, a sterile covered basin containing one obturator which fits in the tracheotomy tube, one Complete trache- otomy tube which is the same size as the one in the trachea, an electric hot plate, a 2-quart covered basin half filled with water, pipe cleaners, wire applicators, absorbent cotton, a small bowl of hydrogen peroxide, silver polish, pencil and paper, paper or gauze wipes, and a paper bag pinned to the bed within easy each. When the room is fully set up the nurse feels secure and independent because not only can she take care of the patient more efficiently with all the facilities at hand, but also because she does not require aid from others. Insuring Patency. The nurse must understand that the trache- otomy is not the ultimate object but is only a means to pipe air into the lungs. Her primary responsibility is to ensure free pas- sage of air through the tube by keeping the tube patent. There is usually considerable discharge of secretion which, when not coughed out, must be removed by suction; a clogged tube causes asphyxiation in a few minutes. The Coughing and rattling sound produced by the mixture of mucus and air are an indication for suction. The patient should be taught not to cough forcibly to expel the mucus but to indicate to the nurse when suction is necessary for removal of excess mucus. It is difficult even for an adult to cooperate in this way; in the case of a child it is impos- sible. Forceful coughing may cause hemorrhage. When the se- Cretions are forced out they should be wiped away quickly and gently before they are inspired through the tube. Breathing is less difficult when a thin layer of moistened gauze saturated in 2 per cent sterile boric acid solution is placed over the opening of the tube so that the air is humidified and filtered. The excess solution is expressed so that there is no dripping. After the sponge is unfolded it is placed over the mouth of the 502 SURGERY OF THE EYE, EAR, NOSE AND THROAT tube and is held in place by tucking it under the tape about the patient's neck. The apprehension of the patient which is frequently encoun- tered is often attributable to his frightening experience of partial or complete laryngeal obstruction before operation. The nurse should be reassuring and calm. She should give him detailed ex- planations concerning his care so that if he is an adult he is un- consciously learning how to care for himself. When constant at- tention is no longer necessary the patient should have a bell placed within reach so that he can summon a nurse quickly. Care of the Tube. The surgeon usually orders that the inner tube be cleaned every hour for the first few days and as often as the nurse feels that it is necessary after that period. The removal of the inner tube is not difficult but it should be done gently and smoothly. A slight jerk of the tube may start violent coughing. While the guard tube is held firmly with the left thumb and fore- finger, the inner tube is withdrawn with the right hand. The tube is cleaned by placing it in a bowl of hydrogen peroxide to harden the mucus so that it is more easily removed. When the tube is small in size a pipe cleaner is repeatedly inserted and drawn through the tube until the tube appears entirely clean when it is inspected in a good light. Absorbent cotton on a wire applicator is more satisfactory for cleaning larger tubes. Tarnish- ing occurs quickly; the use of silver polish will keep the tube shining. While the tube is being cleaned dents and irregularities are prevented by handling it without force. An improperly fitting inner tube is dangerous and also wasteful because it requires the discarding of all three parts. The tubes are handmade and are interchangeable only when more than one was originally made for the guard tube. The inner tube is boiled for one minute in the basin on the hot plate. It is reinserted with the same precau- tions with which it was removed. Decannulation. The insertion of a tracheotomy tube is often a temporary measure. In such cases, before removal of the tube, the patient must be made to breathe normally by a gradual obstruc- tion of the tube. Part of a Cork is placed in the mouth of the tube, and if there are no signs of respiratory distress or obstruction the size of the cork is increased until the tube is completely ob. structed. When the patient is comfortable and shows no ill effects, the tube is removed and the opening is permitted to heal. This process usually takes several days and is known as decan- nulation. NURSING IN OTOLARYNGOLOGY 503 Learning to Talk. Patients with a tracheotomy should not be permitted to whisper but should be encouraged to converse in writing; they are able to talk if a cork is inserted in the tube or when the tube is removed and the trachea is closed. Patients with total laryngectomy will not be able to talk in the natural manner and must wear a tube permanently. They can learn to talk by two methods; the most useful is by means of an esophageal voice. This method is acquired by the mastery of the ability to Swallow air, to force it back from the stomach and to form words out of the belch when it returns. The voice sounds like that of a patient who has a severe case of laryngitis but it is quite under- standable, and is indeed a source of great enjoyment and satis- faction to the patient. This process of learning requires much patience, persistence and initiative. It is accomplished most easily under the direction of an instructor. Care of Tube by Patient. When a patient is to be discharged with a tracheotomy tube it is essential that he be able to care for himself without hesitancy or apprehension. If a child, the person responsible for him is taught by demonstration of the changing and cleaning of the tube. When possible, instruction is begun several days before discharge so that practice under the super- vision of a nurse may be carried out to make certain that the care is completely understood. THE EAR The external ear is composed of skin and cartilage, and the external opening (external auditory meatus) leads to the ear drum (tympanic membrane), a tightly stretched diaphragm which receives Sound waves and accurately transmits their vibrations. The ear drum forms the external wall of a small cavity called the middle ear. Within the middle ear are the three ossicles (malleus, incus, and stapes), a chain of tiny articulated bones joining the ear drum and the internal ear, and serving to transmit the vibra- tions of Sound to the internal ear. Leading off from the cavity of the middle ear is the eustachian tube, which opens into the nasopharynx; this tube has for its function the equalization of air pressure between the middle ear and the atmosphere. The middle ear, internal ear, and mastoid cells are all within the temporal bone of the skull. The mastoid Cells are similar to the accessory nasal sinuses, but communicate through a minute opening with the cavity of the middle ear. The internal ear is composed of the spiral cochlea, which con- 504 SURGERY OF THE EYE, EAR, NOSE AND THROAT tains the auditory nerve endings which are stimulated by the sound vibrations, and the three semicircular Canals, each per- pendicular to the others, which are the end organs of the special sense of equilibrium. Surgery of the External Eqr Congenital Deformities. These are relatively Common. The ear may be partly or almost completely absent, or it may be large and prominent. Such deformities often cause the afflicted child to be an object of ridicule and may give rise to serious personality dis- turbance; fortunately a skilful plastic surgeon can do much to repair the disfigurement. Trauma. Because of its exposed position, accidental injury is fairly frequent, but the ear has an excellent blood supply and even the severest lacerations heal admirably if properly treated. Inspissated Cerumen. Another exceedingly Common affection is the accumulation of wax (cerumen) in the external auditory meatus, which causes impairment of hearing and sometimes pain; this is removed gently under direct vision, although it is neces- sary at times to soften the wax by the application of a drop or two of oil. Foreign Bodies. Children and psychotic patients insert foreign bodies into the external meatus, with resultant pain and inflam- mation; as a rule these objects are easily removed. Inflammation. A condition troublesome to Cure is chronic in- flammation (external otitis) of the meatus caused by fungus in- fection. This is common, particularly in those who engage in aquatics; the symptoms are itching, discharge, and pain. The local application of various chemical disinfectants is helpful in some cases, but no specific therapy has been devised. The use of boric acid powder containing 1 per cent iodine has proved useful in treating this condition. Carcinoma. Cancer of the external ear is also a Common lesion. It is treated by a combination of radical excision and radiation therapy, which is sufficient if the deeper tissues are not invaded at the time treatment is undertaken. Disedses of the Middle Ecur ACUTE OTITIS MEDIA Acute purulent inflammation of the middle ear cavity is common, especially in children. The pathogenic bacteria gain en- NURSING IN OTOLARYNGOLOGY 505 trance through the eustachian tube, so that the disease is a Com- plication of acute infection of the upper respiratory tract, par- ticularly if there is infected adenoid tissue about the pharyngeal orifice of the eustachian tube. Coughing, sneezing, or anything which causes sudden elevation of the intrapharyngeal air pres- sure tends to force air and bacteria into the middle ear. Aerotitis, an occupational disease among aviators, is a middle ear infection produced in this manner. The symptoms are severe earache and impairment of hearing. Fever and leukocytosis occur. On ex- amination the ear drum on the affected side is seen to be in- flamed and bulging. Treatment. As in any purulent infection, the proper local treatment is to establish drainage early in order to prevent Com- plications; this is done by making a tiny incision through the ear drum (myringotomy). General anesthesia is necessary. Relief of pain is almost immediate, and in the uncomplicated case healing of the drum without impairment of hearing takes place after a few days of drainage. Less severe attacks of acute otitis media are successfully treated by sulfonamide or penicillin therapy, as the usual bacterial in- vaders are streptococci, staphylococci, or pneumococci, against which these agents are most effective. In patients in whom the drum is red but not bulging, the need for myringotomy may be averted if chemotherapy is started at once. The prevention of Otitis media, however, is the best safeguard against loss of hear- ing or more serious complications; this has already been dis- cussed under the subject of infected nasopharyngeal adenoid tissue (p. 493). Complications. The Complications of repeated attacks of otitis media or of improperly treated or neglected otitis media are serious. These include scarring of the drum, chronic perforation of the drum, Osteomyelitis of the Ossicles, mastoiditis, and perma- nent impairment of hearing; occasionally brain abscess or menin- gitis follow, and death is not unknown. These complications may occur even in a promptly treated case if the infection is over- whelming, and in such cases chemotherapy (sulfonamides and penicillin) is often life-saving. MASTOIDITIS Infection of the mastoid cells of the temporal bone is a serious complication of otitis media. It is indeed fortunate that this in- 503 SURGERY OF THE EYE, EAR, NOSE AND THROAT fection responds well to therapy with sulfonamides or penicillin or both; before the days of chemotherapy mastoiditis was a pro- longed illness, usually requiring surgery. Mastoiditis is suspected iſ purulent discharge persists after acute otitis media, or if there are pain, tenderness, and redness over the mastoid process of the temporal bone. Fever and leuko- cytosis are variable. Roentgenograms may show clouding of the mastoid cells. Treatment. Rest in bed, antibiotic therapy, adequate diet and fluids, and narcotics for the relief of pain, are begun at once. The majority of patients show improvement within twenty-ſour to ſorty-eight hours, and the symptoms and signs subside in a few days. Mastoidectomy. If the discharge from the ear persists for from three to four weeks, any infection in the sinuses or nasopharynx should be searched for and eliminated. If the discharge from the ear persists another two or three weeks, a simple mastoidectomy should be done or chronic mastoiditis with permanent damage to hearing may result. Fortunately, due entirely to the sulfonam- ides and the antibiotics, a simple mastoidectomy is a very rare operation, whereas fifteen years ago it was an exceedingly Com- II].OIl OIl62. The simple mastoidectomy is performed on those patients in whom the infection is limited primarily to the mastoid cells. The operation is performed under general anesthesia. A curved in- cision is made behind the ear, and the bone of the mastoid process is exposed. All infected mastoid cells are removed with rongeurs and curette, taking care not to injure the facial nerve which controls the movements of the facial muscles. This nerve passes through the temporal bone and may be in extremely close contact with the inſected mastoid cells. Two other important structures which must be looked for and avoided are the lateral venous sinus of the brain and the dura mater. The wound usu- ally heals in a matter of weeks, the ear ceases to discharge pus, and the hearing returns to normal. An ear that continues to discharge pus for a long time (a mat- ter of months or years) does so because there is a chronic inſec- tion in both the mastoid cells and the middle ear. These infec- tions rarely respond to antibiotics or sulfonamides. To eradicate this infection a radical mastoidectomy is required. This opera- tion is similar to the simple mastoidectomy, but in addition to removing the mastoid cells the drum is removed, and also all NURSING IN OTOLARYNGOLOGY 507 middle ear structures with the exception of the stapes. After this operation, the hearing does not return to normal. In fact, it may be even further reduced. It is important to remember that if acute otitis media is ade- quately treated, there will be fewer and fewer cases requiring a radical mastoidectomy. NURSING CARE. Before operation, the head is shaved on the affected side for a distance of about 3 inches around the ear. The preoperative preparation is like that given any patient who is to have general anesthesia. After operation routine care is given the patient; but when there is a sudden or gradual rise in tempera- ture the nurse should be aware of its significance. Many times it is indicative of the dangerous complications which can follow mastoid infections and it should be reported to the surgeon im- mediately. Decifness Loss of hearing is a common complaint, even among children; it constitutes a serious handicap. The problem is being handled in three ways. Efforts are being made to prevent deafness by re- ducing the incidence of ear infections; along this line it has been found that the routine examination of school children followed by radiation of the nasopharynx of those who need it reduces to a large extent the incidence of defective hearing. In the second place, the attempt is made by the use of electronic amplifying devices to render seriously impaired hearing serviceable, and to further decrease the deaf patient's handicap by teaching him lip-reading. Lastly, Continuing efforts are being made to learn more about the causes of deafness and to perfect procedures which will restore hearing that has been lost. Defective hearing is of two types: conductive deafness, in which the loss of hearing is due to impaired conductive powers of the drum, ossicles or wall of the middle ear as a result of injury or disease; and nerve deafness, in which the impairment is due to injury or disease of the cochlea or the auditory nerve. Patients who have only a moderate hearing loss of either the conductive or nerve type are greatly benefited by the use of a properly fitted hearing aid. One Common type of conductive deafness is otosclerosis. It usually affects young people in their twenties. There is often a strong family history of otosclerosis, as a woman with the disease may transmit it to her children. In otosclerosis new bone forms 508 SURGERY OF THE EYE, EAR, NOSE AND THROAT around the stapes and thus prevents movement of this ossicle. Fortunately, a well-fitted hearing aid enables these patients to hear amazingly well. In recent years an operation has been de- vised, the ſenestration operation, popularly called “window op- eration,” which holds out great hope for these patients. In this operation a tiny opening is made in one of the semicircular canals. This procedure apparently allows the sound waves to by-pass the drums and ossicles and enter the inner ear directly. SUMMARY The majority of patients who have diseases of the ear, nose or throat do not require hospitalization. Serious infections, if neglected, can lead to deafness and even death; fortunately, most serious infections are now readily controllable by antibiotic therapy. Patients who have a tracheotomy need constant, expert nursing until they have been trained to care for themselves. VOCABULARY REVIEW laryngoscope otitis media tracheotomy pharyngoscope aerotitis decannulation adenoids epistaxis mastoiditis audiometer tonsillectomy fenestration SUGGESTED READING . Conley, John J.: Tracheotomy. Am. J. Nursing, 52:1078–1081 (Sept.) 1952. 2. Bellam, Gwendoline: Tonsillectomy Without Fear. Am. J. Nursing, 51: 244–245 (April) 1951. 3. Gardner, Warren H.; Rehabilitation. After Laryngectomy. Pub. Health Nursing, 43:612-615 (Nov.) 1951. 4. Greene, James S.: Speech Rehabilitation Following Laryngectomy. Am. J. Nursing, 49:153–154 (Mar.) 1949. 5. Hall, James T., and Sadler, Julia Bland: Nursing Care in Tonsillectomy and Adenoidectomy. Am. J. Nursing, 47:537-539 (Aug.) 1947. 6. Hardy, William G.: Teamwork in the Prevention of Hearing Impairment in Children. Pub. Health Nursing, 43:278-279 (May) 1951. 7. Holmquist, Emily W.: Nursing the Adult Tracheotomized Patient. Am. J. Nursing, 47:310–314 (May) 1947. 8. Jackson, Chevalier, and Jackson, Chevalier L.: Diseases of the Nose, Throat and Ear. Philadelphia, W. B. Saunders Co., 1945, pp. 269-278. 9. Is Your Patient Deaf Am. J. Nursing, 52:578 (May) 1952. 10. Lewis, Donald K.: Deafness. Am. J. Nursing, 52:575-578 (May) 1952. 11. Martin, Hayes, and Ehrlich, Harry E.: Nursing Care Following Laryngec tomy. Am. J. Nursing, 49:149-152 (Mar.) 1949. 12. Proctor, Donald F.: Preventing Deafness in Children. Am. J. Nursing, 49: 45–47 (Jan.) 1949. l Unif XI. NURSING IN ORTHOPEDIC SURGERY CHAPTER 43 Deformities of the Bones, Joints and Muscles INTRODUCTION The skeleton forms the framework of the body, and its con- stituent bones are individually rigid. The body, nevertheless, possesses great flexibility and a variety of movements, achieving that result from the many joints within the framework and from the powerful action of the skeletal muscles. Abnormality of growth, injury, or disease can so alter any of these structures that proper function is partly or entirely lost. About two hundred years ago a French physician conceived the idea that some of the musculoskeletal deformities of the adult might be the Consequence of improper posture during childhood, and, if so, they were preventable. He began, therefore, to advo- cate the importance of correct posture in children, and for this new concept he coined the term “orthopedics,” meaning literally 509 5 10 NURSING IN ORTHOPEDIC SURGERY “the straight child.” From this beginning the specialty of ortho. pedic surgery has come to include all aspects of the surgical care of the musculoskeletal system. Growth and Repair of Bone. In the fetus the skeleton is at first composed of cartilage. The large cells of this tissue produce a light-weight, firm, clear substance called hyaline cartilage. It is tough, but without the rigidity of bone. As the infant grows this cartilage is replaced by bonelike (osteoid) tissue, which has the characteristic architecture of bone but is not yet hard. The bone- forming (osteogenic) cells arise from the sheath of the bone (periosteum) and, like cartilage cells, are originally derived from primitive connective tissue cells. Later, bone making (ossification) takes place in the bone ends (epiphyses) and in the shaft (di- aphysis), calcium salts being deposited in the Osteoid tissue. This calcification is responsible for the natural hardness of bone. In all the long bones, however, there is a zone between the shaft and the bone end in which cartilage cells persist and con- tinue to grow. It is the activity of this zone, known as the epiphyseal line, which accounts for the elongation of the bones during the growth of the child. In the adolescent, between the ages of 17 and 20, this cartilage is finally replaced by bone; the epiphyses are thus united with the shaft, and the person grows no taller. Repair of damage caused by injury or disease is accomplished by a process very similar to the original formation of bone. The blood clot which occurs as a result of a fracture is organized into granulation tissue, and this is then transformed into osteoid tissue, which finally becomes calcified bone. The same process OCCurs when granulation or scar tissue forms in the course of healing in bone infection. As a rule, the repair of bone is carried Out SO efficiently that the natural architecture is almost com- pletely restored, and later little trace of the injury remains. Influence of Diet. For the proper formation of bone an ade- quate diet is essential. A deficiency of vitamin C causes scurvy, which, in babies, results in deformed bones because of inter- ference with growth at the epiphyseal line. More common, how- ever, is rickets. In this disease, caused by deficiency of vitamin D, the bones are not properly calcified, permitting deformity of the abnormally soft bones which bend under the weight of the body or from the pull of the muscles. Sufficient calcium and phos. phorus salts must be contained in the diet, or calcification cannot be completed. Softening of the skeletal bones may occur in DEFORMITIES OF THE BONES, JOINTS AND MUSCLES § 1 I & Acromioclavicular Lib. Coracoclavicular Lú, g *>ººl =2^ Coracoacromion Lig. oſ \ Wendon cº W biceps, M. \ (long head) FIGURE 128. Shoulder joint. women during pregnancy or lactation unless the mother's diet contains calcium in excess of the usual need, for calcium goes into the fetal bones, or into the breast milk, even when the mother is suffering from deprivation. Influence of Glandular Secretions. The influence of the hor- mone secreted by the parathyroid glands in controlling calcium and phosphorus metabolism is now well known, and bony changes occur as a result of disorders of these glands (see Chap. 34). Oversecretion (hyperparathyroidism) permits loss of cal- cium from the body, with consequent softening of the bones. Mechanics of the Joint. The least movement of the body requires the use of one or more joints, and these marvelous struc- tures serve so efficiently and so faithfully that the ordinary per- son scarcely heeds their existence until he is confronted by painful or impaired function. In general, the joints and their accessory structures are designed to furnish motion without fric- tion; they must also be strong enough to withstand stress and Strain. 5 12 NURSING IN ORTHOPEDIC SURGERY Each bone of the skeleton is articulated, that is to say, it is connected with another bone or several other bones by means of a joint or joints. The several kinds of joints are classified accord- ing to the sort of motion permitted. Thus, without entering into a highly technical consideration of the subject, one finds these chief varieties: hinge joints, permitting motion in one plane; gliding and rotary joints, permitting motion in two planes; and ball-and-socket joints, permitting motion in all three planes. The knee joint and the joints of the fingers are examples of the hinge; the wrist and ankle are gliding joints; the shoulder and hip are ball-and-socket joints. The end of every bone entering into an articulation is covered with fibrocartilage, a tough substance which protects the bone end from injury and wear. The entire inner surface of each joint is lined with a smooth self-lubricating membrane, the synovium. Composed of connective tissue cells, this lining membrane se- cretes a glairy fluid, the synovial fluid, which serves to lubricate the joint surfaces, a very small amount being sufficient for this purpose. The entire joint is contained within an envelope of tough fibrous tissue, the capsule. The integrity of the joint is further maintained by the supporting ligaments. These are, in reality, strategically placed thickenings of the articular capsule, which provide stability to the joint and act to prevent movement of the articulating bones beyond the natural limits of the joint. As a rule, the ligaments are situated where the muscles about the joint are weakest. Small accessory sacs of synovial fluid are located outside of the joints to prevent undue friction from the rubbing motion of such muscles and tendons as overlie the joints. These structures are called bursas. Although the location of the larger ones is con- stant, there is a considerable variation in the size and number of the bursas to be found about any given joint. Impaired Function. As the result of injury or disease, various kinds of damage to the different joint structures occur. The ar. ticular cartilages, in particular, fail to heal when damaged, so that impairment of joint function follows. The synovial mem brane, however, is capable of complete regeneration; but occa sionally, when opposite surfaces are injured or diseased, the repair may result in the adhesion of the opposing surfaces. [ſ only a few adhesions form, the joint function is not severely im: paired; but numerous dense adhesions may result in severe loss DEFORMITIES OF THE BONES, JOINTS AND MUSCLES 513 of motion (fibrous ankylosis). Under favorable circumstances, joint capsule and ligaments heal readily with complete return of ſunction; but following loss of substance due to repeated injury or to disease these structures may become weak or useless. When a joint has been badly damaged, healing is sometimes accompanied by excessive scarring, followed by calcification. The final result is complete immobilization of the joint (bony ankylosis). Occasionally, on the other hand, as the result of in- juries that destroy the supporting ligaments and otherwise weaken the joint capsule, an unstable joint is produced. Anatomy and Physiology of Skeletal Muscle. In Contrast to the smooth involuntary muscle found in the gastrointestinal tract and elsewhere in the body, the fibers of skeletal (voluntary) muscles appear striped (striated) when seen under the micro- scope. These muscles, which are able to produce bodily motion by virtue of their ability to contract, usually arise from one bony surface (origin) and are attached (insertion) to some point on the surface of another bone by means of a fibrous band (tendon). Thus, the muscles act upon the bones like a force ap- plied to a lever, the fulcrum being the joint. Voluntary muscle is controlled by the central nervous system; if this nervous telegraph system is interrupted at any point between brain and muscle the person can no longer exert his will over the contraction of the muscle, and its function is lost. Each muscle of the body has a well-defined function, and all of the muscles are so arranged that each has an adversary, an oppos- ing muscle. As no muscle is ever completely relaxed unless para- lyzed, the coordinating action of the central nervous system is of the utmost importance since motion is accomplished only by simultaneous contraction of one group of muscles and relaxation of the antagonistic muscles. Flexion of the index finger (the beckoning gesture), for example, requires not only contraction of the flexor muscles but also simultaneous and equal relaxation of the extensor muscles. In extending the finger this process is reversed. Effects of Injury. Striated muscle fibers are highly specialized structures; if injured, they die and are replaced by scar tissue. The loss of muscle tissue is permanent, and although hyper- trophy of the remaining fibers may compensate for a small loss, an extensive loss of tissue results in reduced power. Interestingly enough, muscle fibers atrophy when not used for a long time. Extremities immobilized because of injury or disease should be 514 NURSING IN ORTHOPEDIC SURGERY treated to prevent the atrophy of disuse, lest permanent loss of power result. The local use of heat, passive movement, massage, and electrical stimulation aid in preventing atrophy. CONGENITAL AND ACQUIRED DEFORMITIES Deformities are common; some are congenital, being already present at birth, and others make their appearance later in life. There is also a variety of causes for these deformities. Some are hereditary, the defect descending from generation to generation; some are the result of nutritional deficiency; and others follow improper postural habits or mistreatment of the body, as from poorly fitting shoes. Additional deformities occur when, through disease of the central nervous system, there exists an imbalance of muscle tone. That deformities result from injuries or from the ravages of neoplastic or infectious disease is well known; these will be considered later. Chondrodystrophia Fetalis. This is a hereditary deformity the chief feature of which is the improper development of the fetal cartilages. This inherited characteristic is responsible for the oc- currence of many of the dwarfs seen on the stage and in the C 1 TCUIS. Curvature of the Spine From a functional standpoint it is inadequate to think of the spine as a Collection of two dozen or so assorted vertebrae. On the contrary, the spine is a complicated organ composed of nu- merous ligaments, muscles, and vertebrae, each purposefully designed and placed. The spinal cord is housed within the spine, and the paired spinal nerves issue from it. The head is supported by the spine, which also serves as the point of attachment for the many muscles of the shoulder girdle, the pelvis, and the trunk. Furthermore, the spine is amazingly flexible, permitting a wide range of motion in every direction. The anatomic construction of the spine is such that, in addition to its other functions, it acts as a shock absorber so that the numerous jolts received in walking or other activity are equally distributed. In a normal person standing upright the spine is straight in the lateral plane, but in the anteroposterior plane it has several gentle curves. There is a slight convexity anteriorly in the cervical and lumbar regions, whereas the convexity is posterior in the thoracic and sacral regions. There are four possible deviations from the normal, including lateral curvature (scoliosis), exag DEFORMITIES OF THE BONES, JOINTS AND MUSCLES 515 * * sº~, | ) # yf ºs} FIGURE 129. Curvature of spine. Left to right: normal; lordosis (Swayback); kyphosis (hunchback); scoliosis (lateral curvature). gerated anterior convexity or sway-back (lordosis), exaggerated posterior convexity or humpback (kyphosis), and rotation on the long axis. As a rule, two or more of these abnormal curvatures are combined, one or more secondary curvatures compensating for the primary deformity. Causes. In the light of present knowledge it seems likely that nearly every deformity of the spine has a true pathologic basis, and that few curvatures are the result of poor habits of posture. Parents who note poor posture in their children should consult an orthopedic surgeon; little improvement results from ad- monishing the child to “stand straight!" Common causes of spinal curvature are rickets, inequality in the length of the legs, flat feet, congenital malformation of vertebrae, high heels, ab- normalities of growth including unequal rate of growth of bones and muscles, neurologic disorders such as poliomyelitis, poor eyesight, infections and tumors of the spine, and injuries. Treatment. The treatment naturally depends upon the cause and type of the curvature. If the lesion is a longstanding one, with structural deformity, little can be done; but if treatment is 516 NURSING IN ORTHOPEDIC SURGERY started at the beginning of the deformity, much can be accom- plished in the way of prevention and restoration. Of first im- portance is the treatment of the disease which is affecting the spine, so that further deformity will be prevented. Next is the use of mechanical measures to compensate for abnormalities, as the use of a thick-soled shoe to lengthen a short leg, thus level- ing the bony pelvis. When the curvature is due to muscle weak- ness a brace may be provided to do the work of the paralyzed muscles, thus serving as antagonist to the remaining muscles which, if unopposed, would pull the spine out of line. Muscles not hopelessly damaged may be strengthened by special exer- cises designed to overcome local muscle weakness. BACKACHE This commonest of complaints is attributable to man's way of living, his upright posture and method of locomotion, and the many ways in which he uses his back. Injury and disease, too, cause backache, the severity of which may seem out of all propor- tion to the nature of the injury or disease. It is also important to remember that pain felt in the back may be referred from elsewhere; thus pain from a stomach ulcer or a gallstone is occasionally felt only in the back, and must be differentiated from true backache. When the spine is permitted or forced for long periods to as- sume curves which are more extreme than normal, the spinal muscles become fatigued and painful spasm occurs. This type of backache Commonly follows long hours of sitting in an improper attitude or sleeping upon a bed which does not support the body Correctly. Upon resumption of normal posture the muscles soon become rested, and the pain disappears. Prevention of further backache depends upon the avoidance of cramped or slouch- ing positions, and upon the use of a mattress and a bed spring which are firm enough to support the body without sagging. An additional measure for the prevention of further trouble is postural training, composed of exercises carefully designed to strengthen those muscles which aid in supporting the back, notably the abdominal muscles. The use of high heels by those not accustomed to them or the wearing of flat heels by those habituated to high ones often causes severe backache because the tipping of the pelvis requires a compensatory bending of the spine. The natural lumbar DEFORMITIES OF THE BONES, JOINTS AND MUSCLES 517 lordosis may be badly exaggerated by the forward pull of the heavy abdomen of an obese person or during pregnancy, and again backache is the result. Those of us who never forsake the city become used to walking on hard sidewalks and streets and do not realize how well the spine absorbs the jolt caused by each step; but that this pounding oſten causes backache is thoroughly appreciated by the Country- man who visits the city. Often, too, people are careless about rundown heels and walk about on the exposed nails, which do not absorb the shock as do rubber or leather heels. When the spine is deformed by disease, backache often accom- panies the constant muscular effort to overcome the abnormal curvature. A brace, properly adjusted to aid the muscles, is the most effective means of relieving the pain. Occasionally, backache is the result of abnormal mobility of the spine, which causes over- activity of the muscles and ligaments. A brace may not be suſ- ficient, and at times operation is indicated. Mechanical defects must first be corrected, iſ possible, before fusion is considered. Fixation of the spine is accomplished by a fusion or bone-grafting procedure to bring about ankylosis of the intervertebral joints. Deformities of the Legs and Feet Congenital and acquired deformities of the lower extremities are far more common than those of the upper. With respect to the congenital deformities, no adequate explanation of this dis- parity has been offered, but the production of acquired deformi- ties of legs and feet is no doubt encouraged by the strain of weight bearing and by the unconcern of many people in their selection of style and fit of shoes. DISLOCATION OF THE HIP In common with some other congenital deformities, dislocation of the hip is not apparent at birth. In most instances the disloca- tion is due to an abnormal forward rotation (anteversion) of the neck of the femur, so that there is both failure of the femoral head to press into the hip socket (acetabulum) and stretching of the joint capsule. Occasionally the dislocation is due to ab- normal shallowness of the acetabulum. In either case, the head of the femur is not firmly fixed in its socket, and when the inſant begins to stand the head of the femur gradually slides upward and backward. It is interesting that congenital dislocation of the 518 NURSING IN ORTHOPEDIC SURGERY hip is more common in female infants, and that it is rare in Negroes. In about half the cases the deformity is bilateral. Con- genital dislocation of other joints is rare. This deformity may affect one or both legs, and attention is called to it by a rapidly progressive limp or waddle as the baby learns to walk. Occasionally a diagnosis of this condition, partic- ularly if it is unilateral, can be made before weight bearing begins. A sharp-eyed nurse may note a difference in the crease of the buttock (gluteal fold) with widening of the perineum. Treatment. The condition should be treated as soon as recog- nized; and, in babies of 2 years or under, cure usually results from manipulation followed by fixation in a plaster cast for six to eighteen months. Lorenz, a Viennese surgeon, introduced this method, which was widely publicized under the title of “blood- less surgery.” Open reduction is sometimes necessary, however, particularly if the joint capsule is badly deformed or if the acetabulum fails to grow properly. The most successful procedure is the “shelf” operation, in which the acetabulum is deepened. CLUBFOOT Those well versed in romantic literature think of clubfoot (talipes equinovarus) as a Common Congenital deformity, and So it is; yet scarcely a person thus deformed is seen on the streets, a tribute to the success of the modern treatment of that condition. To visualize the deformity, one may picture a person walking with foot turned inward in an extreme manner so that his weight is actually borne on the outer surface of his ankle. A normal foot can assume the position of a clubfoot, but the clubfoot is fixed in that position. It is thought that imbalance of muscular pull is responsible for the production of this deformity, although mal- position in utero has also been suggested. There are other varie. ties of clubfoot in addition to the equinovarus, but the latter is the commonest; 85 per cent of all cases are of that type. l Treatment. Treatment is begun in the first weeks of life; if it is not, structural changes in the bones develop, lessening the chance of cure. The deformed foot and ankle are manipulated into correct position in gradual stages, the gain being maintained each time by the use of a plaster cast. Finally, as walking begins, a light brace is used until the muscle balance is sufficiently re. stored to prevent recurrence. When treatment of a clubfoot has been postponed or neglected until bony changes have already occurred, a wedge osteotomy | DEFORMITIES OF THE BONES, JOINTS AND MUSCLES 5 19 %2. % *})) . …,’ſ % ~~ * º | '% /.2% * * * * º & sº 3/3 ,” ºr ~. !. zºº $ * * , , 2 ºf ||fºº} f... ?, - St. #. * -: , sº Nº. 15:...? º FIGURE 130. Left to right: normal; flatfoot (pes planus); clubfoot (talipes equinovarus). can be performed. This operation straightens the foot, but such a foot is usually weak and functions poorly. FLATFOOT Flat foot (pes planus) is an extremely common disability; in- terestingly enough, however, many people have flat feet which do not cause symptoms. In other words, it is not the flatness of the foot which causes trouble; it is a question of its relation to the function of the whole weight-bearing mechanism. Thus, one person may have a perfectly functioning leg and foot with flat arches, whereas another may have poor function with high arches. In the latter case it is a disturbance of the arches which is likely to produce symptoms. There are two arches in the foot, the long arch (from heel to toes) and the transverse (metatarsal) arch. The weight of the body, transmitted through the tibia, should be equally dis- tributed to the heel and to the ball of the foot. If the foot is turned outward (pronated), it is seen that the line of weight bearing passes medially to the midpoint of the arch, throwing great strain on the medial ligaments and calf muscles which support the long arch. Iſ these structures are unequal to the task, the unsupported arch gives way, and a ſlatfoot is acquired with resultant pain and deformity. This is but one of the many types of acquired flatfoot. Treatment. A lift along the inner edge of the heel and sole of the shoe will shift the line of weight bearing laterally. This meas. ure, combined with exercises to strengthen the muscles support- 520 NURSING IN ORTHOPEDIC SURGERY 32- § Y £:= - = $s *= is %22+. SS % = 2+... ; 25; 㺠º żºs ?==% ºf %:#1-####Es **=#:-º º -- *#2 sº-Sº, º ż N Sºzºsº lº º ż, sº ~ >†< se: T-2 ºr ŠSS §s Sº Sé 5:#2 § § 5 is ºf "S㺠SNY. : sº ŞN Nº) §§ Šº S M. {\ s S. # :::::. SS § - §º FIGURE 131. Bunion (hallux valgus). ing the arch, and training to make the patient turn his foot straight ahead as he walks, will as a rule relieve the symptoms. As in other orthopedic conditions, unless treatment is undertaken early, structural changes take place that prevent a good func- tional result. The use of a plate to support the arch is occasion- ally necessary, but will not relieve the symptoms unless the un- derlying causes are treated as well. Metafarsal Pain. High heels, by throwing an undue amount of weight upon the ball of the foot, may produce a flattening of the metatarsal arch. Here, again, relief of symptoms depends upon the restoration of normal weight bearing, and a support beneath the metatarsal arch will not relieve the pain if the patient con- tinues to wear high heels. BUNION Hallux valgus, the deviation of the great toe toward the second toe, is a deformity produced by ill-fitting shoes and is generally associated with anterior arch weakness. Less severe bunions are cured by the wearing of wide shoes. Deformities Caused by Dietary Deficiencies The deformities which occur in association with scurvy and rickets have been mentioned (p. 510). Osteochondrosis. This term has been suggested for another type of deformity which may be the result of a deficiency, but which is at present of unknown etiology. The various growth DEFORMITIES OF THE BONES, Joints AND MUSCLES 521 centers (epiphyses) are affected, and fragmentation of hyaline articular cartilage takes place with temporary pain and loss of function. When occurring in the hip it is known as Legg-Perthes disease; when in the bony prominence below the knee, as Os- good-Schlatter disease. The spine and the upper extremity may also be affected. Treatment by the use of splints is designed to prevent further deformity. Rest, adequate diet, and physiotherapy are also ad- visable. Deformities Caused by Disease of the Nervous System POLIOMYFLITIS Poliomyelitis (infantile paralysis) is an acute contagious dis- ease affecting the spinal cord. It is caused by a filtrable virus. There is no infection of the musculoskeletal system; but as a re- sult of injury to the motor nerve cells of the spinal cord, various skeletal muscles may be seriously weakened or paralyzed, a state which may be temporary or permanent. Treatment. In all cases of poliomyelitis in which any muscular weakness is apparent, Orthopedic treatment is begun just as soon as the acute febrile illness has subsided. The purpose is three- ſold. Weakened or paralyzed muscles must be supported at once with splints, or else the antagonistic muscles, if stronger, will produce deformity; secondly, weakened and paralyzed muscles must be stimulated by physiotherapy and graduated exercises, so that a maximal amount of function may be regained; and finally, where there is permanent loss of muscle power, substitution must be made either by the use of braces or by corrective operations which lengthen contracted tendons or add stability to joints rendered weak by paralyzed muscles. If the muscles of respiration and the diaphragm are weakened, the disease may prove fatal. It is in these cases that the “iron lung" (respirator) has occasionally been life-saving. Of particu- lar benefit to the patient convalescing from poliomyelitis is the Water bath or swimming pool, for the weakened muscles can often move an extremity as it floats in water, relatively unin- fluenced by the pull of gravity. Kenny Method. The Kenny method, named for the Australian nurse who popularized it, has as its basic concepts the main- tenance of normal position and the reeducation of muscles. According to Miss Kenny, the pain in poliomyelitis is due to the Severe contraction (spasm) of the affected muscles. During the 522 NURSING IN ORTHOPEDIC SURGERY acute stage of the illness the patient is kept on a thin mattress upon a wooden flooring (fracture board) instead of springs; a second board is set at right angles at the foot of the bed, and the patient's feet are placed against this to prevent footdrop; no fur- ther splinting is done. The patient is made as comfortable as pos- sible by the use of pads, pillows, or blankets as supports for the affected parts. These are gradually removed as the pain sub- sides. During the acute muscle spasm, hot wet packs are applied to the muscles involved. These are continued until the spasm is relieved. While the patient is critically ill, the packs are given only to the chest and neck to avoid tiring the patient; during this time the patient is handled as little as possible; alcohol rubs are omitted because they are said to increase spasm. Later, active and passive exercises are used. The carrying out of the Kenny treatment is entirely a nursing procedure. SPASTIC PARALYSIS A very different type of lesion of the nervous system produces an equally tragic deformity of the musculoskeletal apparatus. In Little's disease (spastic paralysis of children) severe spasticity of the muscles of two or all of the extremities is due to a cerebral lesion. This disease has been ascribed to congenital brain defects, and also to intracranial injury from prolonged or violent child- birth. The extreme spasticity of the muscles prevents normal movement. Sudden stimuli may provoke immediate extension of arms and legs as a response. If walking is possible, it is with a mincing, tiptoe gait. Frequently the brain abnormality is such that there is little or no mental development, although many sufferers have normal intelligence. Coordination is sadly lacking. No form of treatment has resulted in a cure, although careful muscle training, at times combined with operations on the motor nerves, may restore a useful degree of voluntary control over the spastic muscles. These patients are most effectively handled in the “hospital schools.” THE HOSPITAL SCHOOL The care of severe musculoskeletal deformities, and often of infections and injuries as well, is usually a long-term problem. If the patient is a child, there is apt to be much loss of school and of the normal play and social activities which are so important to the normal growth and development of the individual. If the patient is an adult, the problem is likely to be one of adjustment DEFORMITIES OF THE BONES, JOINTS AND MUSCLES 523 to the deſormity, and of retraining the individual. The social and economic significance is obvious. Because of the special problems involved in the way of program, staffing, and equipment, it has been found best to develop specialized institutions designed to provide a combined program of medical care, education and rehabilitation. SUMMARY The smooth action of the muscles upon the jointed framework of the human body makes possible the variety of movement of which man is capable. Congenital and acquired deformities can prevent a child from taking a normal part in living and can take away from an adult his livelihood and place in society. The cor- rection of musculoskeletal deformity is often a long-term prob- lem, best handled in special institutions in which medical care, educational and rehabilitory facilities are combined. VOCABULARY REVIEW orthopedic bursa clubfoot ligament ankylosis bunion synovial kyphosis poliomyelitis scoliosis SUGGESTED READING 1. Allen, Lucy E.: Congenital Dislocation of the Hip. Am. J. Nursing, 47: 722–726 (Nov.) 1947. 2. Billig, Harvey E., Jr.: The Specialist Looks at Everyday Medical Care in In- dustry: Orthopedics. J.A.M.A., 146:1179–1 183 (July 28) 1951. 3. Ferderber, Murray B.: Rehabilitation Program for the Aged in Two County Institutions. Pub. Health Nursing, 44:664–667 (Dec.) 1952. 4. Grice, David S.: Talipes Equinovarus Diagnosis and Treatment. Am. J. Nursing, 51:707–709 (Dec.) 1951. 5. Howorth, M. Beckett: Your Feet and Your Shoes. Am. J. Nursing, 52: 1368–1372 (Dec.) 1952. * 6. Knocke, Lazelle S.: Some Common Types of Braces. Am. J. Nursing, 52:868– 869 (July) 1952. 7. Ladd, Margaret P.: The Bent Pin: Posture, Industry, Nunse. Pub. Health Nursing, 39:609–612 (Dec.) 1947. 8. Lewin, Philip: Orthopedic Surgery for Nurses. Philadelphia, W. B. Saun- ders Co., 1947, pp. 138–148. 9. Leavitt, Darrell et al.: Scoliosis. Am. J. Nursing, 50:198–202 (April) 1950. 10. Macdonald, Mary: Talipes Equinovarus, Nursing Care in the Community. Am. J. Nursing, 51:711–712 (Dec.) 1951. ll. Stimson, Barbara: Backache, Am. J. Nursing, 51:672–674 (Nov.) 1951. 12. Williams, Barbara J.: Talipes Equinovarus, Nursing Care in the Hospital. Am. J. Nursing, 51:710–711 (Dec.) 1951. CHAPTER 44 Musculoskeletal Injuries Injuries to the musculoskeletal system are in fact wounds of the muscles, tendons, joints, with or without attendant injuries to the bones. As with all wounds, these are open or closed, and they may be produced in a variety of ways. Muscles, tendons, and the ligamentous portions of joints may be severed in a deep lacerated wound, or they may be avulsed by an object striking with the force due to high velocity. Although bone is often exposed by a deep laceration, it is not easily divided; it is frequently shat- tered, however, if struck with great force. War wounds and those resulting from industrial, railroad, or automobile accidents are commonly open, whereas the injuries received in civil life as a result of accidents occurring in the home or in athletics are usu- ally closed. The treatment of open wounds has been discussed in Chapter 2 (p. 13). Wherever possible, divided tendons, nerves, muscles, and joint structures are approximated by sutures, but often this ideal treatment is not possible. In these deep wounds inſection by spore-bearing bacteria (e.g., tetanus, gas gangrene) is always a possibility, and adequate preventive measures must be taken, including cleansing of the wound, débridement, and the use of antitoxin and antibiotics. Experience gained during World War II has shown that it is exceedingly dangerous to attempt imme. diate closure of fresh battle wounds of the extremities because of the likelihood of anaerobic infection. Following débridement these wounds are left wide open, and are lightly packed with ster. ile gauze. Secondary closure may be carried out several days later. Healing is facilitated and the patient's comfort increased, espe: cially when transportation is necessary, by the use of adequate splints. Prolonged immobilization of muscles, tendons, and joints, on the other hand, leads to disastrous stiffening with loss of function. In patients who have had suture of divided tendons, motion must be begun as soon as the healing is sufficiently strong to permit of it. Movements must be restricted at first, them gradually increased up to full performance. In civil life closed wounds of the musculoskeletal system are 524 MUSCULOSKELETAL INJURIES 525 more common than open wounds. These injuries include tear- ing of the muscles, tendons, or joint structures, dislocation of the joints, and fracture of the bones; two or more are usually Com- bined. Hemorrhage always occurs and pain, tenderness, swelling, and disability are regularly present. Such wounds are produced by blows, by falls, by lever action, and by any violence that forces a muscle, a joint, or a bone beyond its normal limits. In this last Category are included those injuries which are the result of Sud- den forceful muscular contraction, for example, the “pulled ten- don” of the sprinter and the fractured humerus of the baseball pitcher. INJURIES TO JOINTS Any trauma to a joint which is severe enough to damage the Synovial membrane causes an effusion of serous fluid. The fa- miliar “water on the knee” is an example of such an effusion into a joint (hydrops), and commonly follows a severe injury to the knee. When a joint is subjected to violent movement beyond its nor- mal limits the result is (1) tearing of the supporting ligaments, muscles, and tendons (sprain); (2) tearing of ligaments and avulsion of bony insertions (fracture-sprain); (3) tearing of the joint capsule with dislocation; or (4) dislocation with fracture. The clinical symptoms and signs of these related injuries differ chiefly in degree, and often it is only by x-ray evidence that a correct diagnosis can be made. Immediate pain and swelling occur in all, and the deformity and disability (loss of function) are sometimes pronounced. The joints most frequently injured are the ankle, wrist, knee, elbow, shoulder, and hip, and the type of injury is usually charac- teristic. Thus simple sprains (i.e., without fracture) of the ankle are of common occurrence, but sprains of the wrist are com- plicated by fracture of the scaphoid or the distal end of the radius. Injuries to the knee usually result from lateral or twist- ing strains, with damage to the semilunar cartilage and crucial ligaments, structures not found in the other joints. The charac- teristic injury to the elbow is a fracture dislocation; the hip and shoulder are commonly dislocated without fracture. Treatment. Treatment depends upon the nature of the injury, and to be successful, therefore, must be based upon correct diag- nosis. Simple sprains are treated by rest and immobilization, Which permit the torn structures to heal. Elevation of the part 526 NURSING IN ORTHOPEDIC SURGERY Wi. \ Ǻ IIIº FIGURE 132. Method of applying adhesive tape to support a sprained ankle, Note that patient holds bandage beneath sole of foot to maintain desired position during application of adhesive. Care in taken that no adhesive strap completely encircles the extremity, in order that there will be no constricting band when swelling occurs. and hot applications will reduce the swelling and relieve the pain. Immobilization can be adequately maintained by the use of properly applied adhesive strapping which fixes the part in the position best suited for healing. Thus an ankle which is sprained by inversion of the foot should be strapped with the foot in eversion. Weight bearing is avoided for the first forty-eight to seventy-two hours, after which it may be gradually resumed. Mas: sage and hot applications accelerate healing, and full use is per- mitted in seven to ten days. Fracture-sprains must be treated as are other fractures, with adequate reduction and fixation; fracture-dislocations are treated in the same way, although these often require special methods of treat Iſlent. Simple dislocations are treated by reduction of the dislocation, followed by immobilization of the joint to permit healing of the damaged capsule and ligaments. Most dislocations are easily re. duced if the patient is anesthetized sufficiently to secure relaxa: tion of the muscles. Traction on the extremity in a direction exactly opposite to that of the force which caused the injury usually brings the displaced bone end into position. In reducing dislocations there is need for expert manipulation without undue force, for ill chosen, violent maneuvers may succeed only in frac MUSCULOSKELETAL INJURIES 527 | * FIGURE 133. Types of fracture. Left to right: greenstick, impacted, and com- minuted. turing the displaced bone or in further traumatizing the joint capsule and other related structures. The use of a sling, or of a Velpeau bandage which fastens the arm against the thorax, is suf- ficient for the immobilization of shoulder and elbow dislocations. In dislocations of the hip, however, weight bearing must not be permitted until torn capsular structures have had time to mend. Rest in bed usually provides adequate immobilization. Following repeated dislocations the joint capsule and liga- ments sometimes become so weak or relaxed that dislocation occurs after minimal trauma or even during normal activity. Operative treatment is usually necessary for the cure of this habitual dislocation, some type of plastic procedure being re- quired to reestablish joint stability. FRACTURES If the skin over the broken bone is intact the fracture is con- sidered simple; in compound fractures there is an open wound. An incomplete fracture is called a greenstick fracture. If the frag. 528 NURSING IN ORTHOPEDIC SURGERY ments are driven together the fracture is said to be impacted, but if the bone is shattered into several small fragments, the fracture is comminuted. The line of fracture may be transverse, oblique, spiral, or T-shaped. A pathologic fracture is one in which a bone is broken by a ſorce far less than that required to fracture it nor- mally; this type occurs only in bones weakened by preexisting disease, such as syphilis, derangements of calcium metabolism, or neoplasm. The diagnosis of a fracture can nearly always be made upon the history of the injury and the appearance of the part, but should be confirmed by x-ray examination. Properly taken roent- genograms ſurnish additional information as to the nature and position of the fragments, and may even disclose an unsuspected fracture. Accurate details of the manner in which the injury was received are of value, since many types of injury are produced in characteristic ways. Pain, swelling, deformity, and disability occur constantly and are diagnostic. The alterations of normal landmarks and the limitation of motion are sufficient for a pre- sumptive diagnosis of fracture without an attempt to elicit the barbarously painful sign of Crepitus (grating of one bone end upon the other). Trecitment of Frcuctures It must be remembered that severe trauma to the adjacent soft parts always accompanies the breaking of a bone, and that there will be hemorrhage and often shock. Whether the shock is solely the result of loss of blood or fluid into the tissues, or is in part due to the severity of the painful stimuli, is a moot point; in any case the condition requires prompt treatment. The emergency treatment of a fracture or suspected fracture, therefore, is to apply a splint which will temporarily immobilize the broken bone. This treatment serves to reduce the element of shock, to prevent conversion of a simple fracture into a compound one, and to make transportation of the patient more feasible. Ap- plication of the oſten repeated aphorism, “Splint 'em where they lie,” has saved many lives. Reduction and Fixation. In reducing (setting) fractures the general principle is to bring the more easily controlled fragment into line with the less controllable fragment. When the fracture is reduced—that is to say, when the fragments are correctly aligned—the broken bone is immobilized by some means, usually a plaster cast, until bony union occurs. The final step in treat- MUSCULOSKELETAL INJURIES 529 º s sea iſ ºr º 2^ * gº& * ſ | | \ f \ —T. S \\ s—T FIGURE 134. Skeletal traction. Fracture of femur is being reduced by traction applied through lower end of femur by means of a Kirschner wire. Countertraction and support of the Thomas splint are accom- plished simultaneously by the overhead pulleys and weight. ment is the restoration of function by graded exercise and physiotherapy as soon as the union is sufficiently strong. The majority of simple fractures can be reduced satisfactorily by manipulation of the fragments while the patient is under the influence of an anesthetic agent; the fragments are immobil- ized in a plaster cast which is applied at once. There are many fractures, however, which for a variety of reasons cannot be treated so simply. In the first place, the bone may be broken obliquely, so that the ends slip upon each other; or there may be many small fragments which do not fit together solidly. Another factor is the pulling action of the strong muscles, which may cause slipping and overriding of the bone ends. In addition to simple manipulation there are at least four methods of securing reduction and fixation. These are skin traction, skeletal traction, external fixation, and open reduction with or without internal fixation. It must be emphasized that no single method produces satisfactory results in every type of fracture; the experienced surgeon secures good results by selecting the best method for each fracture. Traction. In reduction by skin or skeletal traction the distal fragment is slowly pulled into line with the proximal fragment, by means of a weight. Anesthesia is unnecessary, but narcotics to relieve pain are required during the hours or even days neces- 530 NURSING IN ORTHOPEDIC SURGERY sary to accomplish reduction by this means. In skin traction the pull of the weight is transmitted to the extremity by means of adhesive tape attached to the skin distal to the fracture. This method is simple and effective, but it has disadvantages. The adhesive tape frequently slips or tears, and it will not withstand a strong pull, so that occasionally it will not bear a weight suf- cient to overcome the powerful pull of the muscles. In skeletal traction a steel wire (Kirschner wire) or a pin (Steinmann pin) is driven through the distal end of the broken bone; this may be done easily under local anesthesia. The weight is then at- tached by means of ropes and pulleys, and a much more direct and forceful pull can be obtained. In either method the extrem- ity is maintained in the optimal position by means of a splint which fits snugly against the pelvis or shoulder girdle, affording countertraction. In using traction methods it must be remem- bered that there is little effect without countertraction; an un- opposed weight will only pull the patient down or across the bed as the case may be. Countertraction may be obtained by the use of weights opposed to those pulling on the distal fragment, or by tilting the bed and using the pull of gravity upon the patient as the counterweight. When reduction has been obtained by trac- tion and sufficient union has occurred to prevent slipping of the fragments, a plaster cast may be applied and the traction dis- continued. External Fixation. For external fixation, mechanical devices such as the Roger Anderson or Stader anatomic splints are avail- able. By means of two or more wires or pins inserted into the bones, the fragments are aligned and fixed. These splints are especially useful in badly comminuted fractures of the long bones (such as an injury from an automobile bumper). Internal Fixation. Internal fixation may be secured in various ways. By an open operation the fragments are exposed, aligned under direct vision, and fixed by means of wire, vitallium plates, or screws. This direct method of reducing fractures is used when simpler means are inadequate. Another method is the use of a nail driven through the skin into the fragments. This is especially useful in treating fractures of the head of the femur, as it obviates the use of the cumbersome hip spica cast, shortens the length of time to be spent in bed, and permits early use of the leg. The fragments are aligned under the fluoroscope; with local anes- thesia and aseptic precautions a metal (vitallium) nail is driven through the neck of the femur into the head, fixing them to- MUSCULOSKELETAL INJURIES 531 Figure 135. X-rays of fracture of right humerus. Upper, Before reduction; lower, fracture reduced and fragments held in place by means of vitallium plate and four screws. gether. In some fractures of large long bones, such as the femur, an intramedullary pin is used; in this method a metal bar is placed in the marrow cavity on either side of the fracture. Treatment of Compound Fractures The open wound which is always a part of a compound frac- ture may permit contamination of the broken bone by fragments of clothing, particles of street dirt, or other foreign material. In 532 NURSING IN ORTHOPEDIC SURGERY addition to these sources of infection, bacteria lying on the skin may reach the depths of the wound. It must be remembered that the spores of B. welchii are often recoverable from the skin of the perineum and upper thighs. A second factor, of equal im- portance, is the crushing and devitalization of muscle incident to the fracture of the large bones. This traumatized tissue serves as an ideal culture medium for the growth of bacteria, particu- larly the anaerobes. It is obvious, furthermore, that this type of injury is also likely to produce shock. In former times it was considered proper to convert a com- pound fracture into a simple one by closing the wound and treat- ing the fracture in the same way a comparable simple one would be treated. World War I added the invaluable step of débride- ment, the removal of all devitalized tissues. And now, as an out- growth of World War II, a different technic has been evolved. In this method débridement and reduction are followed by simple packing of the open wound with sterile gauze and applica- tion of a plaster cast. When ſeasible, a secondary or delayed closure of the wound is carried out. The final result is excellent, and the mortality very low. It is probable, however, that the first described method is often more satisfactory for the treatment of compound fractures sustained in civil life, where earlier treat- ment is the rule. Penicillin is used, and should be administered in large doses from the outset of treatment, as its greatest value in this field lies in the prophylaxis of infection. Tetanus antitoxin must be given as well. The condition of the extremity and that of the patient must be watched so that the onset of a gas bacillus infection may be detected early. Penicillin and wide surgical exposure of the inſected area will at times suffice to cure an early gas infection, but in the later stages a radical amputation may be necessary. Complications of Fractures Ischemic Palsy. Hemorrhage and swelling accompany every fracture, and in a closed space may compress the blood vessels, thus shutting off the circulation of the blood. The anatomic arrangement in certain locations, particularly in the region of the elbow, forearm, and leg, favors this constriction. The re- Sultant lack of blood (ischemia) produces death of the tissue; thus there may be actual loss of skin or muscle. This serious Complication, known as ischemic palsy, is preventable. Care must be taken that casts or circular bandages are not too tight: MUSCULOSKELETAL INJURIES 533 for this reason the fingertips or toes are always left exposed so that the condition of the circulation may be constantly observed. If cyanosis, undue pain, or swelling develops, the cast or bandage must be loosened at once, or permanent damage will result. Deformity. Improper reduction of a fracture often leaves per- manent deformity and disability, particularly if a joint has been injured. Nature accomplishes wonders, however, and if the pa- tient is intelligent and cooperative, much can be done toward the restoration of function. It is well to remember that early motion is imperative in fractures about the wrist, elbow, and shoulder, where mobility is important; prolonged immobiliza- tion, on the other hand, is required when weight bearing is the important consideration, as in fracture of the lower spine, leg, and foot. Embolism. The marrow cavity of a long bone contains many blood vessels and much fat. It is easy, therefore, in the course of a fracture for droplets of fat to enter the veins, and fat em- bolism does occur as a complication of severe or multiple frac- tures. Paralysis and mental confusion are observed, and there may be pulmonary and renal complications. Death may result from massive embolism, but this is uncommon. Nonunion. Nonunion is an occasional complication of frac- tures, and is difficult to treat successfully. A number of causes may be listed, including insufficient fixation, which permits too much motion at the fracture line; interposition of muscle be- tween the bone ends; infection of the bones; Syphilis; neoplastic disease; old age; and dietary deficiency. Each of these causes necessitates specific treatment, but occasionally there is no ap- parent cause and no treatment is successful. In such a case the line of fracture is not bridged by bony healing; instead, there is a fibrous union, with loss of stability and, at times, formation of a false joint. SPINAL INJURIES The common types of spinal injury include compression frac- ture of the vertebral bodies, dislocation, fracture of the spinous or articular processes, and rupture of the intervertebral disks. Of first importance in the consideration of spinal injuries is the possible presence of injury to the spinal cord, a grave complica- tion (see Chap. 40). In the absence of damage to the spinal cord, spinal injuries may be successfully treated by reduction when possible, followed by the application of a plaster jacket or 534 NURSING IN ORTHOPEDIC SURGERY sº Né tº | g º tººkli *- R º § &lſº | º #!!! | - | #AXºlº | * * Qºcº º FIGURE 136. Reduction of compression fracture of lumbar vertebra by hypc) extension. The Gatch frame is reversed, and the spring is re enforced with a hinged fracture board. Lower figures show effect of hyperextension upon the compressed vertebra. metal brace which immobilizes the spine until healing has occurred. Dislocations and fracture-dislocations usually occur in the cervical spine, and follow falls upon the head, as in diving into shallow water. In these there is a high incidence of serious dam age to the cord, usually with fatal outcome. Compression frac. tures are Common in the lower thoracic or lumbar region as a re- sult of a fall in the sitting postion. In these fractures cord injury is less common, and cure follows proper reduction and im mobilization. Avulsion fractures of the spinous or transverse processes are usually due to sudden twisting injuries and to vio- lent muscular pull. Painful but not serious injuries, these frac. tures respond well to proper fixation. The diagnosis and treat ment of dislocated or ruptured intervertebral disks are described in Chapter 40. Muscular and ligamentous sprains of the back are common, usually resulting from weight liſting with the back bent at a dis advantageous angle, or from a twisting, reaching motion as, for example, in placing a heavy object on a high shelf. The more serious of these sprains injure the lumbosacral articulations, and MUSCULOSKELETAL INJURIES 535 are extremely painful and disabling. In mild injuries, adhesive strapping, rest, and heat are sufficient to obtain a cure; but in severe lumbosacral injuries a brace, or occasionally spinal fusion, a surgical procedure designed to immobilize the joint by a splint of grafted bone, may be required. NURSING CARE IN MUSCULOSKELETAL INJURIES The nursing care of orthopedic patients presents many prob- lems not encountered in caring for other types of Surgical pa- tients. Such patients are of all ages; the individual, aside from the present injury, may be either physically fit or suffering from a chronic illness such as tuberculosis. The orthopedic patient is often hospitalized for long periods of time—months or even years —during which he may be able to do little for himself. It is not enough to see that such a patient's bed is changed, his tray brought, and his elimination regular. Means must be found to occupy his mind, so that it is not warped by the long confinement to bed; in addition, care must be taken to keep the body of the patient as fit as though he were active, so that muscles do not lose their power, nor joints stiffen through disuse. There are numerous technical matters pertaining to Ortho- pedic care that must be mastered. These include familiarity with the preparation and use of plaster casts and Orthopedic appli- ances and apparatus, the care of the patient after they have been applied, and a knowledge of physiotherapy and occupational therapy. As a guiding principle, it is to be remembered that proper care will preserve the function of the musculoskeletal Structures but the restoration of lost function is difficult or im- possible. Care of Patients in Trciction Apparcitus The apparatus rigged up for the purpose of applying traction often appears complicated but is usually simple in principle. It is the duty of the nurse to understand fully what result the surgeon seeks and how this is to be accomplished. The cooperation of the patient is invaluable and may be encouraged by a simple ex- planation of what is being done. It is often necessary for the nurse to readjust the apparatus because dressings may slip, the splint may be disarranged, ropes may jam in the pulleys, and so on. In making the adjustments, however, the nurse must take care that there is no disturbance of the ſundamental principles, that is, there must be no change in the amount of weight used or 536 NURSING IN ORTHOPEDIC SURGERY in the direction of the pull. These considerations are particularly important when moving the patient, as in changing his position or in taking him to the x-ray department. Care of Immobilized Patients. Patients in head traction in the treatment of cervical spine injuries are a problem because of the necessity for immobilization. Traction is applied to the head by means of a padded halter passing beneath the occiput and chin, or by a wire or tongs inserted directly into the skull. Counter- traction is furnished by elevating the head of the bed on blocks so that gravity pulls the patient toward the foot of the bed. The countertraction permits turning the patient. Turning the patient with head and body in a straight line is necessary. The frequency for giving back care depends on such factors as the Condition of the skin, incontinence and emaciation. A full, adequate diet is essential to the proper repair of bone. Eating too fast often produces discomfort, if not actual nausea, therefore it is wise to offer the food in small amounts. The pa- tient should be told what food is being served to him. Because of the mechanical difficulties involved in immobilization, the pa- tient is forced to depend largely upon the nurse for his fluid intake. However, by the use of a drinking tube or similar device, adequate fluids may be given. A clean mouth is not only more comfortable but is also an aid in preventing infection. Regular brushing of the teeth and frequent use of mouthwashes are im- portant. Core of Poitients in Coists Technic of Applying Plaster Casts. Plaster of paris bandages are made by rubbing powdered plaster (calcium sulfate) into the meshes of rolls of crinoline cut into the desired width (2 to 8 inches). Just before actual use the roll is placed on end in a bucket of warm water. Air bubbles will rise. The roll is thor- oughly wet when no more bubbles appear. Excess water is re- moved by grasping the roll at either end and pulling gently; but twisting is avoided as it causes too much plaster to be lost. Plas- ter casts may be padded or unpadded, depending upon the na- ture of the case and the surgeon's preference; padding is more commonly used and consists of glazed cotton and heavy felt. Sometimes stockinette is applied to the skin first. In unpadded casts the plaster is applied directly to the skin. The bandage is applied turn upon turn, even, moderate pressure being used. The greatest care must be taken to avoid wrinkles or dimples MUSCULOSKELETAL INJURIES 537 in the cast as such irregularities are apt to cause pressure sores. Plaster Room. In applying fresh plaster it is impossible to avoid spilling small amounts on the floor and elsewhere; there- fore it is desirable to have a special room for this purpose. A sink with a specially constructed drain and trap is also advis- able, as plaster washed from the hands or remaining in the buckets used for moistening the bandages will quickly plug the ordinary drainpipe. Supplies needed for the plaster room are the following: Acetic acid, 5% Alcohol, 70% Ammoniated mercury ointment, 5% (sterile) Benzine Boric ointment (sterile) Compound tincture benzoin Ether Procaine, 4%% Stearate of zinc powder Talcum powder Petrolatum (sterile) Zinc oxide ointment (sterile) Alcohol lamp Culture tubes (sterile) Syringe and needles for procaine Syringe (Chetwood) Adhesive tape, 3,2,1, and 14 inch Cotton pads Crinoline, starched, 6 and 3 inch Elastic bandages Felt padding Gauze bandages (unsterile), 6,4,3, and 2 inch Gauze rolls, wide and narrow (sterile) Glazed cotton bandages, 6,4,3, and 2 inch Muslin bandages (unsterile) and 2 inch Plaster bandages 6,4,3, and 2 inch Slings (muslin) Sponge rubber Stockinette, 10,8,6,4,3, and 2 inch Surgical dressing cart (equipped as for surgical ward) Webbing straps and buckles 6,4,3, Tape measure Bandage scissors (large) Plaster shears Plaster knives Cast spreader Bending irons Orthopedic table with attachments Hammer Hatchet Mallet Saw Sandbags Splints: airplane, basswood, Coapta- tion, and Thomas Throat sticks Care During Setting of the Cast. As the moisture evaporates, the cast hardens (sets). The initial setting, however, does not make the cast firm. Great care must be taken in the handling of a wet cast. When any lifting is necessary the cast should be sup- ported with the entire hand. Lifting with the finger tips causes indentations which may cause pressure areas. Two factors that are important in drying a cast are: good circulation of air around the cast and even drying by turning the patient frequently. In a warm climate, where there is no danger of chilling the patient, 538 NURSING IN ORTHOPEDIC SURGERY an electric fan may be used to speed the drying. It is important that the drying plaster cast be firmly supported until it has set. In the case of large body casts this may require many hours. Failure to observe this simple precaution of proper support results in the cracking of the cast, which necessitates the application of a new OIl62. The cast is usually supported with pillows. Extremities in casts should be elevated and supported. A straight leg cast may be supported by placing three pillows on an inclined plane from the heel to the hip; one pillow is placed lengthwise under the upper leg, and the other two are placed under the lower leg. This provides for even support. Whenever there is a concavity in the cast it should be supported. A small pillow placed Crosswise at the level of the lumbar curve will give support when a body cast has been applied. During the drying process the patient's extremities are watched carefully for signs of constriction of circulation: Cyanosis, swell- ing, and pain. The patient frequently complains of tightness of the cast and pain. These complaints must be relayed to the doc- tor. Special effort must be made for the patient to describe what the pain ſeels like, for if he says it is “burning” there is urgent need to notify the surgeon immediately. Such pain does not usually last long, but it signifies terrific pressure which will re- sult in necrosis with loss of sensation if the pressure is not re- lieved. These signs and symptoms must be reported immediately in order that the surgeon may, by cutting the cast, release the constriction and prevent the development of ischemic palsy. Plaster on the exposed toes and fingers should be washed off with a damp cloth. The edges of the cast should be bound with ad- hesive tape to prevent crumbling and to strengthen the edges. Turning the Patient. The bed is prepared for the patient by putting a fracture board underneath the mattress. It is hardly necessary to say that a patient in a large body cast is practically helpless. In many instances assistance in feeding is needed. Com- plete turning must not be omitted in any case even though the patient is able to stay on his face for only a short time. For turn- ing patients in large body casts at least two nurses or attendants are needed. One stands on each side of the bed. The patient is moved to one edge (toward side of injured extremity) and is instructed to hold his arms tightly to his sides. The closer nurse elevates her side of the patient by lifting with one hand beneath the patient's chest and the other beneath his thigh; the second FIGURE 137 FIGURE 138 FIGURE 140 FIGURES 137–140. Method of turning patient in cast. FIGURE 139 539 540 NURSING IN ORTHOPEDIC SURGERY nurse steadies the patient and helps to lower him into the new position as he gradually is turned over toward her. Small changes in position may be effected by the use of pillows and pads at the back and between body surfaces. Prevention of Pressure Sores. The prevention of pressure sores calls for the use of every method and device known, and for in- genuity in Creating new ones. Regular care, including inspection of all pressure areas, rubbing, keeping the skin dry, and the relief of pressure as far as possible, are the simplest modes of preven- tion. Rough edges of casts may be taped with adhesive or covered with Cotton pads. The most commonly used materials for protect- ing the perineal region from excretions are waterproof plastics, and oiled silk or oiled muslin. The material is cut in 4 or 5 inch strips which are tucked under the cast. They are held in place on the outside of the cast by adhesive or mending tape. Oiled paper may also be used for this purpose, but it has very little durability and must be changed frequently. An extremity may need to be elevated to relieve pressure at the edge of the cast. Bed cradles or similar devices are used to relieve the pressure of the bedcovers on the toes. Pressure on the heels is relieved by the use of a cot- ton “doughnut” or by a pillow placed underneath the leg so that the heel will extend over the edge. Orthopedic Bed. Modern orthopedic beds allow for the intro- duction of the bedpan below the level at which the patient lies; this not only is easier and more comfortable but also aids in the prevention of pressure sores. The bedpan should be carefully adjusted so that the flesh of the buttocks rests on the edge of the pan. When the edge of the cast rests on the pan, urine will follow the buttocks up under the cast. Elevating the head of the patient on not less than one pillow while he is using the bedpan also helps to prevent him from moistening the back under the cast. A soft pillow or several cotton pads placed between the edge of the pan and the cast will make the patient more comfortable, if Such a bed is unobtainable. BALKAN AND BRADFORD FRAMEs. There are other mechanical devices which aid in the maintenance of position and simplify the Care of these patients. The Balkan frame may be built into the bed, or the portable wooden frame may be attached to any hos. pital bed. It provides support for the apparatus used in traction. A trapeze or other overhead support placed within the patient's reach provides help to the patient in turning and an opportunity MUSCULOSKELETAL INJURIES 54 I for limited exercise. The Bradford frame is a rectangle of iron piping over which canvas is laced tightly. The canvas is put on the frame in two sections, with space enough at the buttocks so that the bedpan may be used without disturbing the patient's position. A valuable feature of the Bradford frame is that it may be bent at any point into the angle the surgeon desires, for the purpose of providing hyperextension. The features of both the Bradford and the Balkan frame are built into the modern frac- ture bed. Removing the Cast. When the cast is to be removed, a plaster cutter, plaster knife, and scissors are needed. The cast is damp- ened along the line of anticipated incision and cut. The removal of the cast is a long awaited event, and to prevent undue worry and depression on the part of the patient he should be warned that all the joints which were in the cast will feel transitory stiff. ness and soreness. After the cast is removed, gentle washing of the part with warm water, mild soap and a soft cloth followed by the application of a little oil is indicated. Ccure of the Convcılescent Patient Crufches. Crutches should be 1 inch shorter than the distance between the axilla and the heel, and should be fitted with rubber tips to prevent slipping. The patient should wear a shoe on the normal foot to offer better support and to allow the injured ex- tremity to swing clear of the floor. The patient is instructed to bear his weight on his hands instead of in the armpit as the pressure due to bearing weight upon a crutch in the axilla is apt to damage the nerves and cause paralysis of the arm (crutch palsy). He is taught to bend forward from the hips. Since it is often necessary that crutches be used for many months, good pos- ture must be learned. Unless the patient is warned he may con- centrate his weight on the ball of the foot, flex the hip, and rotate the knee outwardly. He should be permitted to walk only a few steps the first day. The nurse should be at his side to pre- vent falls until he feels secure and has acquired ease and rhythm in his walk. The tendency to walk with chin on chest and eyes directed to the floor becomes a habit because of insecurity. Atten- tion should be called to this detail when the patient learns to walk. The patient moves both crutches forward together with the injured extremity, bearing the weight on the good leg. Then his 542 NURSING IN ORTHOPEDIC SURGERY weight is shifted to the crutches, and the good leg is brought forward. Short steps, caution, and the development of a smooth rhythm are then in order. The arm rest may be made more Com- fortable by being padded with sponge rubber or with cotton pads, but the patient must be cautioned against bearing his weight on the axilla. Walker. For patients who have not been on their feet for a long time or for those who are timid about using crutches, a device called a walker is useful in the period of learning again how to walk. The walker is a circular metal frame mounted upon small wheels or casters; the patient stands inside the frame, supporting his weight by his hands. The walker may also be fitted with a seat or straps to aid in weight bearing. Braces. In convalescence from bone disease or injury and in the correction of deformity, braces are frequently used. These are made of strong, light-weight materials such as aluminum, leather, or steel. They are used chiefly for the leg (walking calipers), the spine (Taylor spine brace), the arm or elbow, and for the neck. Removal of the brace is ordered by the doctor. Because the effectiveness of a brace depends upon a snug fit, it is a part of nursing care to see that the brace is correctly placed and adequately fastened. Physiotherapy The use of modern physiotherapeutic methods, including mas. sage, passive motion, exercises, water baths (hydrotherapy), bak- ing, diathermy, and sunlight (heliotherapy), constitutes one of the most important steps in the rehabilitation of patients who have had injury or disease of the musculoskeletal system. Nearly every hospital has trained technicians to carry on this work, but often it is the responsibility of the nurse to see that the patient follows instructions and to carry out the treatment outlined by the physiotherapist. The purpose of physiotherapy is to prevent loss of muscle tone, to prevent stiffening of joints, and to attempt to overcome these iſ already present. The cooperation of the pa tient, particularly in the matter of exercises, is essential, and in most instances the degree of return of function following in juries and Orthopedic operations depends to a large extent upon the willingness of the patient to help himself. In each case the treatments and exercises are selected to fit the individual need. Progress is often slow, and it is necessary to keep the patient encouraged. MUSCULOSKELETAL INJURIES 543 Rehdbilitcution Many orthopedic patients face not only a long period of hos- pitalization but also a future with a physical handicap." Aid in making adjustment to these should be given to such patients as early as possible, and his fear and anxiety must be allayed. The reason for restrictions upon his activity should be explained and every effort made to increase his confidence in himself and in his ſuture by encouraging him to do actively for himself everything that is permitted. Occupational therapy is a great aid in re- habilitation. It is unfortunate that all too often insufficient Con- sideration is given to the problem, and poor judgment used in the selection of the type of occupational training. It is a sad mis- take to provide knitting, basket-making, or needlepoint for a patient who may look on these things as “sissy”; much more will be accomplished if the patient is taught to produce something of which he might have been proud even had he made it before he became handicapped. Children requiring long-term hospitalization may miss many months or even years of school; in addition, they usually have a physical handicap which is a source of embarrassment. To meet the needs of these children, institutions called “hospital schools” have been established. SUMMARY Sprains, dislocations and fractures are wounds of the muscles, joints and bones. The treatment of these makes use of the same principles as are involved in healing of all wounds, notably ap- proximation, immobilization, hemostasis, débridement, control of infection, and good circulation of the blood. The necessary use of devices such as traction and splints, and the long periods involved in achieving the healing of bone bring special problems Which need expert nursing care. Rehabilitation must be included in the plan for all patients with serious injuries to the musculo- skeletal system. VOCABULARY REVIEW crepitus medullary mail internal fixation traction ischemic palsy Bradford frame Kirschner wire Balkan frame reduction nonunion * See Brown, pages 766–791. 544 NURSING IN ORTHOPEDIC SURGERY SUGGESTED READING 1. Chesley, A. J. et al: Home Accident Prevention—A Symposium. Am. J. Pub. Health, 40:518–524 (May) 1950. 2. Colonna, Paul C.: Regional Orthopedic Surgery. Philadelphia, W. B. Saunders Co., 1950, pp. 1–21. 3. Funsten, Robert V., and Calderwood, Carmelita: Orthopedic Nursing. 2nd Ed. St. Louis, C. V. Mosby Co.. 1949. 4. Hacker, Garnet I.: Medullary Nail. Am. J Nursing, 50:104–106 (Feb) 1950 5. Miller, Bernice: Well Leg and Hip Splints. Am. J. Nursing, 48:572–576 (Sept.) 1948. 6. Moore, Moore, Jr.: Ambulation Following Fractures of the Lower Ex tremity. Am. J. Nursing, 53:174–175 (Feb.) 1953. 7. Newton, Kathleen: Basic Needs of the Aged. Am. J. Nursing, 50:32–35 (Jan.) 1950. 8. Silverstein, Martin A., and Gips, Claudia D.: Skin Care of the Incontinent Patients. Am. J. Nursing, 52:63–64 (Jan.) 1952. 9. Skinner, Geraldine: Head Traction and the Stryker Frame. Am. J. Nursing, 52:694–696 (June) 1952. 10. Wilde, Delphine: The Patient in a Spica, Abed and Afoot. Am. J. Nursing, 51:429–432 (July) 1951. CHAPTER 45 Inflammatory, Infectious, and Neoplastic Diseases of the Musculoskeletal System A deplorable amount of human suffering and economic loss re- sults from the ravages of the various disease entities included under the heading of musculoskeletal inflammations and infec- tions. Open wounds acquired by accident may serve as portals of entry for invading bacteria; or microbes, having entered the blood vessels from a focus of infection in the tonsils, teeth, Or elsewhere, may be carried to muscles, joints, or bones by the circulating blood. There are some affections which, being obvi- ously inflammatory in character, have been considered to be in ſectious in origin although the actual inſective agent has not been demonstrated. Another group of inflammatory lesions has been thought to be the result of wear and tear during excessive or long use. In all of these, however, the final result, whether due NEOPLASTIC DISEASES OF MUSCULOSKELETAL SYSTEM 545 to actual destruction of tissue or to the formation of scars and adhesions, is likely to be the loss of function. TENOSYNOVITIS Infection of the tendons and their sheaths usually occurs by the direct extension of an adjacent infectious process, which is often a felon or a furuncle. The acute suppurative tenosynovitis which develops is characterized by great pain on motion of the tendon. Tendons have a relatively poor blood supply, and therefore the local resistance to bacteria is not good. Unless the infection is treated early, tendons are quickly destroyed by the common in- vaders, the staphylococcus and the streptococcus. Diagnosis is based upon the systemic signs of infection together with local pain, tenderness over the tendon, and unwillingness of the patient to move the affected part. There is usually some local inflammation, but often this is minimal. Treatment. The infection must be treated by general systemic measures, antibiotics, and local heat and rest. The tendon sheath should be incised early to permit drainage. As soon as the acute inflammation has subsided, physiotherapy, which includes exercise, massage, and passive motion, must be started in order to bring about restoration of function. When loss of substance occurs as the result of neglect or from a very severe infection, plastic procedures are necessary. It must be remembered that the loss of tendons may mean the loss of the patient's ability to earn a living. Gonorrheal Tenosynovitis A Common nonsuppurative variety of acute tenosynovitis is due to the gonococcus and often complicates gonorrhea in both male and female. This type may be diagnosed by the suddenness of onset, without evidence of local portal of entry, and by the presence of gonococcal infection of the genital tract. The ex- tensor tendons of the wrist are the ones most often affected. Rest, splinting, diathermy, and antibiotic therapy result in cure. Tenosynovitis Sicca Tenosynovitis sicca is a low grade inflammation of tendon and sheath of frequent occurrence; it is probably due to excessive use since there is no evidence of bacterial inſection. Motion is pos. sible but is painful, and a characteristic crackling or crepitus is felt over the tendon during motion. As a rule there is little red- 546 NURSING IN ORTHOPEDIC SURGERY ness or swelling. Simple rest by splinting results in prompt dis- appearance of the inflammation with relief of symptoms. DUPUYTREN'S CONTRACTURE A curious deformity of the hands results from a nodular thick- ening and shortening of the palmar fascia. This affection, known as Dupuytren's contracture, is not a true inflammation, and no known infectious agent is concerned. It occurs usually in Cob- blers, mechanics, or others who constantly traumatize the palm of the hand, and, peculiarly enough, the tendency appears to be hereditary. The disabling contracture can be relieved by surgical removal of the diseased palmar fascia. BURSITIS Bursas are occasionally the seat of acute suppuration, usually the result of the direct introduction of bacteria into the bursa. Far more common, however, is a chronic low grade bursitis of nonbacterial origin, probably due to excessive wear and tear. An example of this is prepatellar bursitis, known as housemaid's knee. This is a painful affliction, and is cured only by prolonged rest or by excision of the bursa. The bursas of the elbow (olecranon) and shoulder (subdeltoid) are also often attacked by this chronic inflammatory process, and the condition proves troublesome to athletes and others who use their arms strenuously. MYOSITIS Inflammation of muscle (myositis) is relatively uncommon, largely, perhaps, because of the excellent blood supply of this tissue. Bacterial invaders do not thrive unless the muscle is de- vitalized. Chronic abuse or overuse of muscle is occasionally fol. lowed by low grade inflammation and fibrosis. This chronic form of myositis is sometimes seen in the thigh muscles of cavalrymen, or in the arm muscles of professional baseball players. ARTHRITIS Inflammation of a joint is both painful and disabling. The Common symptom is pain, exacerbated by movement, and on in. spection the acutely inflamed joint is seen to be swollen, with obliteration of the normal anatomic prominences. The diseased synovium produces an excess of fluid, distending the joint cap. NEOPLASTIC DISEASES OF MUSCULOSKELETAL SYSTEM 547 sule and causing the extremity to be held in that characteristic semiflexed position which permits the least tension within the joint. Local heat and redness are also observed. Acute suppurative arthritis is the result of bacterial invasion of the joint and, as in bursitis, may follow a penetrating wound, or may be a blood-borne infection. High fever, leukocytosis, and other systemic responses are usual. Diagnosis is confirmed by aspiration and study of the joint fluid. An acute but nonsuppurative form of arthritis is caused by the gonococcus; it is important to differentiate this from the sup- purative form as the treatment is different. Another variety likely to lead to confusion is seen in acute rheumatic ſever, the cause of which is as yet not known. Since nearly any acute febrile illness may be accompanied by painful joints, proper diagnosis is extremely important. Treatment. The Correct treatment of acute suppurative arthri- tis includes rest, surgical drainage, local heat, immobilization, and antibiotic therapy. In gonococcal arthritis drainage is un- necessary. Early motion of the joint is desirable in order to pre- vent fixation (ankylosis), and thereſore active motion is begun : as SOOn as the acute inflammation subsides. Active motion is bet- ter than passive motion, for the patient is less likely to harm him. self than is the physician or nurse who suffers no personal pain during manipulation of the patient's joint. The treatment of an acute rheumatic joint or of other joint in- ſlammations of a medical nature such as chronic arthritis, rheu- matism, gout, and degenerative arthritis, is nonsurgical in gen- eral, but occasionally, as a result of degenerative changes or in- jury, pieces of cartilage or bone become loose in a joint cavity. Loose bodies are particularly common in the knee, and cause "locking” of the joint. The treatment is surgical removal of the free particles of bone or cartilage. OSTEOMYELITIS Acute Form. The acute form of this disease of bone (acute hematogenous osteomyelitis) is a blood-borne bacterial infection, and the Commonest pathogen is Staphylococcus aureus. Children are the usual victims. The disease is characterized by the sudden Onset of local pain and a severe systemic reaction, including headache, anorexia, nausea, malaise, chills, high fever, and leuko- Cytosis. The local signs are minimal. In the early stages swelling and redness are absent, but the careful examiner discovers one 548 NURSING IN ORTHOPEDIC SURGERY % % ºft * & sºčğ 3. ºś %: § .Nc. !... Nº <2< 7 º’ Ø ; & § % Šºš } ** (; , Požº (%. , * Słł e º °...) 2: *-āinus 3% opening 22s 2. a?/ %22 % §§§ * * :* :* x *—S * | * ~ # /*, Sequestrum yº5 #|\, ń Thickened ºf A.S.: - % Asy periosteum Rlº }% § º #% * FIGURE 141. Chronic osteomyelitis. point where pressure over a bone causes exquisite pain, indicat- ing the site of the infection. It is generally believed that a clump of staphylococci acts as an embolus, plugging one of the tiny end-arteries in a long bone. Deprived of circulation, the local bony tissue is put at a grave dis- advantage, and the bacteria multiply rapidly. Cellulitis develops, and since the bone cannot expand, the pressure of the exudation causes much pain. Suppuration occurs within twelve to thirty- six hours. Unless adequate surgical drainage is promptly carried out, the pus ruptures into the marrow cavity and thus spreads throughout the length of the bone; or it breaks through the cor- tex, elevating and stripping the periosteum from the shaft. In a neglected case both of these sequelae may occur. Diagnosis is based on the symptoms and signs; in the early stages x-ray films show no bony changes. Treatment. In addition to immediate surgical drainage, treat- ment includes general measures, antibiotic therapy, and trans. fusions. Early in the care of the patient the nurse should under. NEOPLASTIC DISEASES OF MUSCULOSKELETAL SYSTEM 549 stand the danger of deformity. The patient usually holds his limb in a flexed position in which there is the least possible strain on the bone and muscles. Foot drop is also apparent early in the disease. The surgeon usually applies a splint of some kind as soon as drainage has been established. This is to hold the limb in an optimal position in order to prevent contracture of the muscles and to add support to the part. Chronic Form. Chronic osteomyelitis was formerly a terrible affliction, and often persisted, with remissions, during the entire life of many patients who contracted the disease in childhood. Antibiotic therapy has completely changed the outlook for pa- tients with this infection. The diagnosis of chronic osteomyelitis is easily made by the history of previous infection of the bone, the presence of a per- sistent, discharging sinus, and the characteristic appearance in the x-ray film of the diseased bone. Frequent acute flare-ups, in which the patient has pain, local inflammation, and fever, are common. Usually due to temporary interruption of drainage of the chronic infection, these exacerbations subside quickly upon the reestablishment of proper openings for the discharge of pus. The nurse should be aware of the great virulence of the organism that is contained in the pus whenever the dressings are changed. The soiled dressings should be placed in a paper bag and burned. She must protect herself and the other patients by thoroughly washing her hands each time she cares for such a patient. Treatment. Antibiotic therapy, using the agent which is most effective against the bacteria responsible for the infection, sur- gical drainage of abscess cavities and the removal of pieces of dead bone (sequestra) constitute the proper treatment. TUBERCULOSIS Modern sanitation and public health measures have done much to reduce the incidence of tuberculosis of the musculo- skeletal system, but it is still too common. Tubercle bacilli enter the bones, joints, and tendon sheaths by way of the blood stream from a primary focus of infection, which is usually in the lungs. Tubercles develop, and are followed by the typical cheesy (caseat- Ing) destruction of bone or joints. As is characteristic of tuber- culous infections, the process is a low grade inflammation, with no redness or local heat, giving rise to the term cold abscess. Joints and tendon sheaths, when infected, become swollen and painful, and unless healing is brought about, function is lost. 550 NURSING IN ORTHOPEDIC SURGERY When bone is infected the caseation produces a crumbling dis- integration, so that pathologic fracture may occur, or deformity of the bone is produced under weight bearing. Humpback (gib- bus), now seen less frequently than formerly, is an exaggerated dorsal curvature (kyphosis) resulting from the collapse of one or more tuberculous vertebrae. Cold abscesses in the soft tissues ad- jacent to tuberculous bone occur frequently, and may burrow along tissue planes for considerable distances, ultimately reach- ing the surface to produce persistent draining sinuses. Treatment. Tuberculous bones and joints will heal if the pa- tient can develop the proper resistance to the infection. As in all forms of tuberculosis, the most important therapeutic measures are rest, both general and local, and adequate nutrition. Im- mobilization of the affected parts is essential. This is accom- plished by proper splinting and by fusion operations. The treat- ment is continued over months or years, until adequate healing takes place. It is common practice to treat patients with tuberculosis of the spine (Pott’s disease) by immobilization upon a stiff support- ing frame (Bradford frame). Reduction of the humpback is ac- complished by gradual hyperextension. The patient is placed on the frame so that the “hump” is directly over the bend in the frame. If the patient is a child or a restless adult, it may be neces. sary to use restraint in order that proper position may be main- tained. This may be accomplished by the use of a jacket that fits over the chest and shoulders and is tied to the frame; in addition, extension may be applied to the feet. If necessary, the frame may be further bent to increase the degree of hyperextension. The essential point for the nurse to remember is the absolute avoid. ance of any motion of the back; turning is done in such a way that the patient moves “all in one piece.” In the beginning the patient will need help in eating and drinking. NEOPLASTIC DISEASE The cells of the various components of the musculoskeletal sys. tem are all of Connective tissue origin, and the neoplasms arising from them are characteristic in appearance and behavior. The commonest tumor is the fibroma, a benign growth composed of simple connective tissue cells with much extracellular fibrous tis. sue. Indeed the fibroma is perhaps the tumor that occurs more frequently than any other single type. It is found in any part of the body that has connective tissue, and in the musculoskeletal NEOPLASTIC DISEASES OF MUSCULOSKELETAL SYSTEM 551 system it commonly arises from fascia, from a tendon, or from the sheath of a nerve. The symptoms and signs of a fibroma are due solely to the mechanical effect of its size and position. The treatment is simple removal, and cure is certain unless tumor cells are left behind. Neoplasms arising from muscles or joint structures are rare, despite the large amount of muscular and joint tissue in the body and the constant degree of use to which they are subjected. Benign tumors of cartilaginous (chondroma) or bony (osteoma) origin are not uncommon. Although benign, these neoplasms are difficult to cure because it is often impossible to remove them completely without performing a mutilating operation. The chondroma is frequently a multiple tumor, arising simultane- ously in several different locations. It is, furthermore, a matter of record that the chondroma, which originally appears to be benign, will, if permitted to grow for several years, often de- generate into a malignant neoplasm. Scircoma Malignant tumors of the connective tissue cells, although not occurring as frequently as malignant epithelial tumors, are never- theless responsible for many deaths annually. It is a fact that the results of treatment are less successful for the various kinds of Sarcoma than for cancer. The tumors are difficult to discover in the early stages, and connective tissue cells are resistant to radium and roentgen irradiation. Sarcoma arises from fascia, tendon, nerve sheath, periosteum, and cartilage. The neoplasm is usually cellular, and the microscopic appearance is sufficiently charac- teristic to indicate the origin of the growth. Invisible and pain- less at first, some sarcomas cause symptoms by pressure on nerves, Some by reason of the size attained, others because of metastases. Roentgenograms are invaluable in diagnosing these as well as Other tumors of the bones. The type observed most frequently is the spindle-cell fibro- sarcoma, arising from either fascia, nerve sheath, or periosteum. Less common is the bone sarcoma (osteosarcoma) which arises from the osteogenic or osteolytic cells of the periosteum or en- dosteum. Another form of malignant tumor of bone is the highly malignant small cell endothelioma (Ewing's sarcoma). The origin of this neoplasm is obscure, and it differs from the others in being sensitive to radiation therapy. The bones are frequently the sites of tumor metastases. Car- 552 NURSING IN ORTHOPEDIC SURGERY FIGURE 142. X-ray film of osteogenic sarcoma, lower end of femur. cinomata of such organs as the breast, thyroid, kidney, and pros- tate often give rise to bony metastases which may be mistaken for primary bone tumors. Differential diagnosis is based upon x-ray appearance, multiplicity of lesions, discovery of a primary tumor elsewhere, or biopsy. Another type of neoplasm, the myeloma, may be confused with bone sarcoma because it attacks the bones. This growth arises from the cells of the bone marrow, and may cause widespread destruction of bone. Bone Cysts Cystic disease of bone has long been of interest to surgeons, but only recently has some light been thrown on the subject. With the discovery of the part played by the parathyroid hor- mone in regulating calcium metabolism, it soon became evident that some bone cysts are due to rarefaction of the bone as a result of the loss of calcium from the body caused by hyperpara- thyroidism. This condition, formerly known as osteitis fibrosa NEOPLASTIC DISEASES OF MIUSCULOSKELETAL SYSTEM 553 gº A -º-º:4. Assis s º §e. 2%: ää sº Sºś º § FIGURE 143. Ganglion of wrist. cystica, is now successfully treated by the removal of parathyroid tumors. Following cessation of the abnormal loss of calcium the cysts disappear. Further discussion of this subject is found in Chapter 34. GANGLION It is difficult to classify this common lesion properly. A tumor in the sense that it is a swelling, a ganglion is in no way a neo- plasm. Ganglions occur about joints, usually the wrist or ankle, and occasionally the knee. The ganglion is a cyst containing synovial fluid, and under the microscope the wall of the cyst re- sembles a joint capsule. As a rule, the lesion is painless but when large it may interfere mechanically with joint function. The most reasonable theory of the nature of origin of the ganglion is that it constitutes a herniation or diverticulum of a joint capsule. The classical method for treating a ganglion was to strike it hard with the family Bible. The blow ruptured the cyst wall and dispersed the fluid. Unfortunately, however, the ganglion thus treated soon returned; permanent cure is effected only by the sur- gical removal of the cyst wall. Since the ganglion nearly al- Ways communicates with the underlying joint cavity, it is essen- tial to find and close the communication in order to prevent TeCurrenCe. 554 NURSING IN ORTHOPEDIC SURGERY SUMMARY Inflammatory disease of the muscles, joints, and bones, whether infectious or not, may lead to serious disability. It is in the pa- tients suffering from these affections that conservation of func- tion and rehabilitation are most useful. Malignant neoplasms arising from the musculoskeletal system are fortunately not of very frequent occurrence. VOCABULARY REVIEW tenosynovitis arthritis sequestrum bursitis osteomyelitis ganglion SUGGESTED READING 1. Anderson, Helen C.: Nursing the Patient with Bone and Joint Tuberculosis. Am. J. Nursing, 48:215–220 (April) 1948. 2. Funsten, Robert V., and Calderwood, Carmelita: Orthopedic Nursing. 2nd Ed. St. Louis, C. V. Mosby Co., 1949. 3. Kilham, Blanche Ann: Nursing Patients with Osteomyelitis. Am. J. Nursing, 50:19–21 (Jan.) 1950. 4. Krause, Marie V.: Nutrition and Diet Therapy. Philadelphia, W. B. Saun ders Co., 1950, pp. 359-368. 5. Leavitt, Harry L.; Bone and Joint Tuberculosis. Am. J. Nursing, 48:213– 214 (April) 1948. 6. Lewin, Philip: Orthopedic Surgery for Nurses, Philadelphia, W. B. Saunders Co., 1947, pp. 187–223. 7. O'Brien, Robert M.: Osteomyelitis. Am. J. Nursing, 50:17–19 (Jan.) 1950. 8. Young, H. Herman: Surgical Treatment of Arthritis. Am. J. Nursing, 48:27- 28 (Jan.) 1948. CHAPTER 46 Abdominal Hernia An external abdominal hernia is the protrusion of abdominal contents through a defect in the abdominal wall. When an open- ing is present, it is not surprising that omentum, intestine, or other movable viscera should be forced through it, because great pressure develops within the abdomen during such acts as lifting a heavy weight, Coughing, sneezing, and the crying of infancy. The local weakness of the abdominal wall is due either to a con. ABDOMINAL HERNIA 555 genital defect, to a weakness in the arrangement of the anatomic structures, or to the imperfect healing of an operative wound. The two common sites of congenital defect are at the inguinal rings and at the umbilicus. Structural weakness, too, occurs in the abdominal wall at the inguinal rings, and also at the femoral rings, in the lumbar regions, and at the openings in the dia- phragm which permit passage of the great vessels and the esophagus. Internal abdominal hernia, on the other hand, is the protrusion of viscera through an abnormal opening in some por- tion of the mesentery of the alimentary tract; such openings may be due to developmental defect, or may be acquired as the result of injury or operation. Hernias are classified according to etiology, anatomic location, and degree. If the hernia or the hernial opening in the abdom- inal wall is present at birth, the hernia is considered to be con- genital in origin; all other hernias are considered to be acquired. The common anatomic sites in the order of frequency of their occurrence are inguinal, umbilical, incisional (postoperative), femoral, internal, diaphragmatic, and lumbar. There are other rare types. A hernia is said to be reducible if it is possible, by gentle manipulation and pressure, to replace the protruding ab- dominal contents within the abdominal cavity; if it is not, the hernia is considered irreducible or incarcerated. When the Con- tents of the hernia are not only irreducible but are so tightly con- stricted by the hermial opening that the circulation of the con- tents is impaired, it is a strangulated hernia. Certain other terms are used in connection with hernias. The hermial ring is composed of the edges of the structures of the abdominal wall between which the hernia has protruded. The hernial sac is the pouch of peritoneum which has been pushed out through the opening by the protruding viscera. The cover- ings of the hernial sac vary in the different locations according to the anatomy of the region. Some hernias are so large that the abdominal cavity is no longer able to accommodate the pro- truded viscera; this type is considered to be a hernia which has forfeited the right of domicile. All operations performed for the repair of hernia (hernior- rhaphy) are the same in principle. The hernia is reduced, the sac is removed, and an attempt is made to close the defect in the abdominal wall. Success depends upon many things: the type of hernia, the age of the patient, the nature of his tissues, but, above all, upon the perfection of wound healing. Thus in hernior- 556 NURSING IN ORTHOPEDIC SURGERY rhaphy there is a special premium upon asepsis, avoidance of tension, and gentle handling of the tissues. INGUINAL HERNIA In order to understand the frequency of occurrence of inguinal hernia and the methods of its repair it is necessary to consider briefly both the anatomy and the embryology of the region. Dur- ing the fetal life of the male the testis migrates from its original site near the kidney, moves down behind the peritoneum, and descends from the abdominal cavity into the scrotum. To do this it must pass through the inguinal canal, a slit-like opening bounded above by the lower margin of the short, lateral abdom- inal muscles, laterally by the inguinal ligament (Poupart's ligament), medially by the lateral border of the rectus muscle, and below by the ramus of the pubic bone. As the testis descends it carries with it a small outpouching of the peritoneum, the spermatic artery and veins, and the duct (vas deferens) through which the spermatozoa pass to reach the seminal vesicle. Under normal conditions, by the time birth occurs the connection of this small peritoneal outpouching with the general peritoneal cavity has disappeared, but in a considerable number of infants the connection persists, and thus constitutes a preformed hermial sac. In some of these inſants hernias are apparent at birth, but in others protrusion of the abdominal contents (either the omentum or intestine) into the sac does not take place until some strain later in life initiates the process. Thus symptoms and signs of a true congenital inguinal hernia may not appear until the first or second decade of life. Acquired inguinal hernia, on the other hand, usually does not appear until later, and is associated with the thinning and relaxation of the muscles and ſascia of the ab- dominal wall incident to obesity and advanced age. Often the differentiation between the two types is difficult before operation, but during the operation a correct diagnosis can be established because of the different relations of the hermial sac to the sper- matic Cord. Both congenital and acquired inguinal hernias are often bilateral. Inguinal hernia is not uncommon in the female, although much less frequent than in the male. The congenital type of hermia does occur because the round ligament of the uterus, the structure embryologically analagous to the male spermatic cord, passes through the inguinal canal to attach to the fascia about the pubic bone. ABDOMINAL HERNIA 557 Incision S- S ^ Loop of intestine in s § Ss s her nial sac § FIGURE 144. Inguinal hernia. The diagnosis of inguinal hernia is usually not difficult. The patient (or his parents or nurse) notices a bulge in the inguinal region which appears on standing or straining, and disappears on lying down. The hernia may descend into the scrotum as far as the testicle; it may be large or small; it may be difficult or im- possible to reduce. There is often some discomfort and a dragging feeling, but actual pain is present only, as a rule, when the hernia is strangulated. Palpation of the scrotum, reduction of the hernia, and palpation of the inguinal ring, revealing enlargement and descent of viscera on Coughing, confirm the diagnosis. Trecitment INGUINAL HERNIORRHAPHY The incision is made just above and parallel to the inguinal (Poupart's) ligament. Each layer of tissue is divided and care- fully preserved so that it may be used in the repair; the division of these structures permits reduction of the hernia if that has not been possible prior to operation. The peritoneal sac is exposed, dissected free, and excised; the peritoneum is closed flush with the normal boundary of the peritoneal cavity. The various lay- 558 NURSING IN ORTHOPEDIC SURGERY Şs • - --> Š ºfºre W §§ E: CŞ=###º sº º W Ød tendon s 9. ºSS }º Interrupted sutures § "sº §º S | Iſº g through inguinal lig. E. --~~ * * % 2% § º * N.º z º W s ºſº § s N º § FIGURE 145. Inguinal herniorrhaphy. The hernial sac has been removed. The internal oblique muscle and conjoined tendon are being sutured to the inguinal ligament, over the spermatic Cord. ers of muscle and fascia are then sutured together in an over- lapping manner (imbrication). Since the spermatic cord must still pass through the abdominal wall in order to reach the testis it is necessary to leave a small opening, but care is taken to reduce the size of the opening to fit snugly about the cord. The opera- tion is readily carried out under general, spinal, or local anes- thesia, depending upon the condition of the patient and the preference of the surgeon. Standard operations for inguinal hernia accomplish the cure of the condition in more than 95 per cent of those patients who have Small hernias and normal abdominal wall tissues. The results are less satisfactory in treating patients who have very large hernial openings and those whose tissues have been weak- ABDOMINAL HERNIA 559 FIGURE 146. Umbilical hernia. ened by age, obesity, or previous attempts at operative repair. The occurrence of strangulation demands an emergency opera- tion, and, at times, necessitates resection of gangrenous intestine or omentum; infection of the wound is not infrequent in such patients, and the rate of recurrence of the hernia is higher than in uncomplicated cases. Nursing Care. There is little that is special about the nursing care of patients following inguinal herniorrhaphy. Infants may be dismissed from the hospital as soon as they have recovered from anesthesia, with instructions for the mother to proceed with ſeedings and care as before operation. Children may remain in the hospital for seventy-two hours, but their activity need not be restricted to bed rest. Adults are requested to ambulate the day after operation; and may leave the hospital in five or six days, by which time the sutures are out, the alimentary tract is func- tioning normally and there is only a little residual discomfort in the operative area. Occasionally, a patient will have difficulty in initiating voiding during the first twenty-four hours; catheterization may be neces. sary. Children may return to school in ten days or two weeks but should avoid strenuous athletics for about a month. Adults should avoid strenuous exercise or hard labor for about six weeks. The above plan may be applied to the care of patients after repair of other abdominal hernia except those in which the de- ſect was very large, including those in which stainless steel or tantalum mesh was needed. Such patients may remain in bed for a few days, and should avoid strenuous activity for three months. 560 NURSING IN ORTHOPEDIC SURGERY SUMMARY An abdominal hernia is a protrusion of abdominal contents through a congenital or an acquired defect in the abdominal wall. The principles of repair include replacement of contents and closure of the defect. VOCABULARY REVIEW incarcerated strangulated inguinal herniorrhaphy SUGGESTED READING 1. Christopher, Frederick: Textbook of Surgery. 5th Ed. Philadelphia, W. B. Saunders Co., 1949, pp. 1191–1224. 2. Gatch, W. D., and Montgomery, W. F.: The Treatment of External Hernias Containing Gangrenous Bowel. J.A.M.A., 129:736–739 (Nov. 10) 1945. 3. Watson, L. F.: Hernia. 3rd Ed. St. Louis, C. V. Mosby Co., 1947. 4. Cogswell, H. D., and Czerny, E. W.; Treatment of Hernias in Infants and Small Children. Am. Surgeon, 19:87–90 (Jan.) 1953. 5. Hagan, William H., and Rhoads, Jonathan E.: Inguinal and Femoral Her nias: A Follow-up Study. Surg, Gynec. & Obst., 96:226–232 (February) 1953. Unif XII. NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS CHAPTER 47 Surgery of the Male Genital Organs The organs of reproduction in the male are the penis, the scrotum and its contents (testes and epididymes), the prostate gland, the seminal vesicles, and the connecting tubes (ducts) which provide passage for the spermatozoa in their journey from their point of origin in the testis to emission from the external penile opening (meatus). The primary function of the penis is copulation; it is richly supplied with nerves and blood vessels, and is composed largely of erectile tissue. The penile urethra, an epithelial-lined tube, serves as the final pathway for both spermatozoa and urine. Empty- ing into the posterior portion of the urethra are the tiny ducts leading from the prostate and the seminal vesicles. The prostate Secretes a glairy fluid which acts as a vehicle for the spermatozoa; the mixture of the two constitutes the semen. The lobes of the prostate gland lie around the urethra just at its junction with the 561 562 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS ight ureter º iSeminal #ºs vesicle Urethra * *== §§-Scy. C §§ ss of U S- s"Testis FIGURE 147. Male genital organs. bladder. The seminal vesicles, one on each side, are located behind and beneath the bladder; these organs act as reservoirs for the spermatozoa, storing them until ejaculation occurs. The vas deferens is the duct which connects the seminal vesicle and testis; it courses laterally and interiorly from the base of the bladder to the inguinal ring, where it becomes incorporated into the sper- matic cord, passing through the ring down into the scrotum to the epididymis and testis. The coiled tubules of the epididymis are a second reservoir for mature spermatozoa. The testis (male gonad) contains the germinal epithelium from which the spermatozoa develop; in addition it contains cells which elaborate the male sex hormones (androgens). These hormones begin to appear in quantity at puberty and are responsible for the development of the secondary male sex characteristics, including the deepening of the voice, the growth of hair on the ſace and chest, the body contours, the awakening of a lively interest in the SURGERY OF THE MALE GENITAL ORGANS 563 opposite sex, masculine aggressiveness, and the like. Mature spermatozoa also make their appearance at puberty and the indi- vidual becomes capable of reproduction. In the absence of disease or injury to these organs the reproductive power persists for many years; at a later and quite variable age the sex power wanes, and the testes atrophy. One functional testis is sufficient for repro- duction, but the loss or maldevelopment of both testes results in the loss of the power; in addition, there is loss of the sex hormone with consequent effects, depending largely upon the age at which the loss occurs. CONGENITAL AND ACQUIRED DEFORMITIES Eunuchism Either maldevelopment or the loss of both testes (castration) in infancy results in the development of a eunuch, a sexless man. Such a person has a soft skin, silky hair, no beard, a high-pitched voice, underdeveloped and functionless external genitalia, and lacks the masculine mental attributes. Castration after puberty has somewhat less effect; the reproductive power is lost, of course, but such secondary characteristics as may have already developed tend to remain. There is often, however, a profound psychologic effect upon the individual. Hermaphrodism Certain of the lower animals possess the necessary organs for functioning as both male and female, but no human being has ever been proved to be a complete hermaphrodite. At rare inter- vals, however, a human being has been ſound who has both a testis and an ovary. Pseudohermaphrodism is less rare; in this condition the person possesses the gonads of one sex but the external gen- italia are abnormally developed and may present the appearance of the opposite sex. In such cases it is a not uncommon error to base the diagnosis of sex upon the appearance of the genitalia, an error which has oſten resulted in the rearing of the child as a mem- ber of the wrong sex; later the development of secondary sex char- acteristics may lead to correction of this error. The genitalia are usually underdeveloped, and operative search for a supposed un- descended testis in an individual with a rudimentary penis may lead to the discovery of ovaries. The observation of serious ab- normality of the external genitalia in a child should lead to sur- gical exploration so that the true sex may be determined; follow- 564 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS ing this, plastic corrective procedures can be undertaken upon the genitalia which, although unlikely to restore full reproductive power, will aid greatly in the rehabilitation of the child and in the prevention of serious personality disorders. Cryptorchidism In the embryo the development of the testis is closely related to that of the kidney; later in fetal life the testis migrates from its position near the kidney, passing behind the peritoneal cavity to the inguinal ring, and finally descending into the scrotum where it is normally found at birth. In about 4 per cent of male infants, however, the descent of the testis is incomplete on one or both sides; the hidden testis may lie within the abdomen or in the in- guinal canal. It was formerly thought that undescended testes would be functionless because of failure to descend, and various surgical procedures were undertaken to bring the testes down into the scrotum. The results of surgery were not invariably satis- factory. Indeed, if untreated, many undescended testes gradually come down just before or at puberty, and a large proportion can be made to descend by administering to the patient a course of injections of the proper hormone (either pituitary or placental gonadotropic hormones. It seems likely that the lack of testicular function in cryptorchidism is due to a deficiency of the proper hormonal stimulation, which is also responsible for the failure to descend, so that a mechanical descent brought about surgically does not of itself bring about testicular function. Phimosis In phimosis the foreskin (prepuce) is abnormally tight, so that proper retraction is difficult or impossible. It is a common defor- mity. Irritation from the resulting uncleanliness leads to infection of the glans (balanitis). Phimosis is cured by partial excision of the foreskin (circumcision), an operation frequently performed upon infants for prophylaxis or because of religious or tribal CUISton]. Hypospadicus Hypospadias is a rare deformity in which there is improper closure of the penile urethra, so that there is an opening in the urethra along the under surface of the penis. Delicate plastic surgery is necessary to close the urethra, or to construct a tube to bridge whatever gap may be present. As in any wound of the SURGERY OF THE MALE GENITAL ORGANS 565 urethra, precautions are taken to keep the wound clean and dry; a small indwelling catheter is connected to a suction apparatus so that urine is drawn constantly from the bladder and given no opportunity to get into the wound. Sedatives are administered regularly during the first few days aſter operation in order to prevent the occurrence of erection of the penis, which would put severe tension on the fresh wound. Chordee As a result of congenital defect, injury, or disease, fibrous bands or scars may be present in the shaſt of the penis, and these, being inelastic, cause a bending of the organ during erection. This de- formity, called chordee, may be so severe as to make sexual union impossible. In many instances sufficient relaxation of the band or scar can be obtained by plastic procedures similar to those used elsewhere in the body for relaxation of scars. Hydrocele In its descent from the abdominal cavity the testis acquires a sheath of peritoneum. Abnormalities of this developmental proc- ess often pave the way for the occurrence of an inguinal hernia, and in other instances a small sac of peritoneum remains in the spermatic cord (the artery and veins of the testis and the vas deferens). Fluid accumulates in this anomalous peritoneal sac, and this is called hydrocele. The fluid-filled cavity varies in size from an almond up to an Orange or larger. It is treated properly by surgical excision. Varicocele Because of the dependent position of the scrotum and its con- tents, there is a tendency of the veins of the spermatic cord to dilate and become varicose; this condition is called varicocele. The enlarged veins feel like a bag of worms, and cause a sensation of weight or aching pain. In less severe cases the symptoms are re- lieved by the wearing of an elastic supporter for the scrotum (suspensory), but sometimes partial excision of the varicose veins is necessary. This operation must be performed very carefully, for injudicious interference with the circulation of the testis results in atrophy. After this operation, as after the operation for hydrocele, an important feature of the care is the wearing of a Suspensory until healing is complete, in order to prevent undue swelling and discomfort. 566 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS FIGURE 148. Catheterization set-up for the male patient; equipment is arranged on the upper and lower shelves of table on wheels. . Medicine glass, syringe, screw clamp 10. Sponge stick in disinfectant solu I 2. Sterile Cotton balls tion 3. Sterile cotton balls in aqueous 11. Sterile urethral catheters Zephiran 1:1000 12. Dressing basin 4. Sterile urine culture tubes 13. Spare instruments 5. Sterile water 14. Paper bags 6. Alcohol lamp 15. Tincture of benzoin 7. Instruments (sterile) 16. Ether 8. Sterile lubricant 17. Unsterile toothpick swabs 9. Sterile mineral oil 18. Adhesive tape, 14 and 1 inch Nursing Cdre in Plastic Repciir In many instances the patient is a child who is anxious about his condition. He asks questions and needs a sympathetic and competent nurse to give him explanations in simple terms which SURGERY OF THE MALE GENITAL ORGANS 567 É º:= § ºº::= FIGURE 149. Catheterization. he can easily comprehend. When his questions are answered in a quiet, reassuring manner he will understand that there is no need to be ashamed or to fear ridicule. Before operation for extensive plastic repair the area that is shaved includes the perineum and genitalia, from the supra- pubic region half way down the inner side of the thighs and around the buttocks. The preoperative preparation is like that for general anesthesia. The delicate plastic surgery used to repair the deformities re- quires great care. After operation the patient is gently moved from the stretcher to the bed to prevent injury to the wound and disarrangement of the dressings. Placing a bed cradle over the pelvis prevents discomfort from the pressure of the bedclothing. The indwelling catheter that is used to divert the urine from the 568 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS wound is attached to a straight drainage apparatus with or with- out suction. The catheter must remain open to keep the operative area constantly dry. Frequent gentle irrigations of the catheter by the injection of a sterile solution with a sterile syringe are use- ful in keeping the catheter open. Each day the drainage tubing is replaced with clean sterile tubing. Aseptic technic is used because there is at times during the replacement a back-ſlow of urine which will be contaminated if the tubing is not sterile. Fluids are forced to keep the specific gravity of the urine low. A regu- lar diet is usually well tolerated. Young adult patients are troubled sometimes by erections after operation. The surgeon usually leaves an order for the nurse to apply an ice cap to the penis for twenty minutes, as required. He instructs the patient, without emphasizing the danger of erec. tion, to call the nurse iſ he feels there is a beginning erection. In addition, the surgeon may order drugs such as bromides or stilbesterol to reduce the occurrence. Conscientious adherence to the principles of cleanliness of the wound helps to prevent infection. Dressings are changed when necessary until the wound is healed, and the patient is instructed not to touch the dressings with his hands. INJURIES OF THE MALE GENITALIA Wounds of the external genitalia are not uncommon. Unless extensive loss of structure has taken place, genital wounds heal favorably because of the excellent blood supply. Contusion of the testis is a very painful injury, and there is usually gross swelling of the damaged organ. Excellent results follow conservative ther- apy, which includes rest in bed, the wearing of a suspensory, and the application of cold. Extensive lacerations of the scrotum occur, usually as the re- sult of catching the trouser and leg of the patient in the moving parts of a machine; the testes are commonly spared. If enough SCrotal skin remains to cover the testes the wound can be closed; otherwise the testes must be implanted beneath the skin of the abdominal wall. Traumatic Castration is occasionally seen, especially among battle casualties; for such patients, treatment consists in hemos- tasis and, later, hormonal-replacement therapy. Injuries to the internal structures, the vasa, the seminal vesicles, and the prostate, are rare except when incident to opera. tlOn. SURGERY OF THE MALE GENITAL ORGANS 569 Perhaps the most difficult to treat of injuries to the genitalia is traumatic rupture of the urethra, a rather common Complication of severe fractures of the pelvis. Rupture of the urethra may be followed immediately by the extravasation of urine and blood into the subcutaneous tissues of the abdomen and perineum; there may be, also, an external urinary fistula. INFECTIONS OF THE MALE GENITALIA Veneredl Infections The treatment of venereal disease in the male, especially gonor- rhea, was once the province of the specialist in surgery of the genitourinary tract; this is no longer the case, for the spectacular results obtained by treating patients who have syphilis and gonor- rhea with penicillin have made it possible for all physicians to cope with these diseases. It is only the occasional patient with neglected gonorrhea who may need the services of the specialist. Infections of the Penis Ulceration of the glans (balanitis) occurs when the tightness of the foreskin prevents retraction and cleanliness. The inflam- matory process subsides and heals rapidly following division of the tight foreskin, or circumcision, and such local measures as moist heat and cleanliness. Specific lesions of the penis include the chancre of syphilis, the chancroidal ulcer caused by the bacillus of Ducrey, and gonorrheal urethritis. The treatment of these lesions depends upon their proper diagnosis, and is not Surgical in any event. Orchitis, Epididymitis Inflammation of the testis and epididymis may be acute or chronic. Acute orchitis is caused by the gonococcus, and by the virus of mumps. Iſ the disease is bilateral, sterility often results. Gonococcal orchitis is a complication of gonorrheal urethritis, and is treated with penicillin, rest in bed, and the wearing of a suspensory. There is no specific therapy for the orchitis of mumps. Chronic orchitis is usually a complication of syphilis, and is treated accordingly. Chronic epididymitis, on the other hand, is usually a feature of tuberculosis of the genital tract, which is treated by surgical removal of the affected portions of of the tract if a general survey of the patient does not show evi- dence of active tuberculosis elsewhere in his body. 570 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS | º #4% º 2.ɺ - - Sº... •e.tº: §§ § * … we sº 22- º % º § ºilº.’-> 3:38 lº a tº. :::::::::::: ::::A; Yºr s ºf. ºr & T) Prostate FIGURE 150. Benign prostatic hypertrophy. Vesiculitis, Prosłcititis The seminal vesicles and the prostate may be acutely inflamed as a complication of gonorrhea. After the acute phase has sub- sided there may remain a chronic infection, difficult to Cure. The symptoms of chronic prostatitis are slight, the commonest being a persistent urethral discharge, small in amount. Examina- tion of the prostatic fluid shows white blood cells and occasional bacteria. Chemotherapy and a course of prostatic massage (ac. complished by pressure upon the prostate from a finger in the rectum) usually clear up this infection. The seminal vesicles also are occasionally involved in tuberculosis of the genital tract, and in some patients cure follows radical excision of the entire tract (epididymis, vas, and seminal vesicle). NEOPLASTIC DISEASE OF THE MALE GENITALIA Benign Prostatic Hypertrophy This extremely common condition, which occurs in over one third of all men beyond the age of 50, owes its gravity to the location of the prostate gland. The exact cause of the hyper- plastic enlargement which the prostate undergoes is not known, but it is probable that it is due to an endocrine disorder, perhaps a male counterpart of the female menopause. In any event, SURGERY OF THE MALE GENITAL ORGANS 57.1 since the prostate is situated at the neck of the urinary bladder surrounding the upper urethra at its junction with the bladder, it is obvious that any significant enlargement of this gland causes obstruction to the outflow of urine. The symptoms of prostatic hypertrophy are frequency of urination, difficult in starting urination, nocturia, and, finally, complete retention of urine. Concomitant with this gradually progressive obstruction is a failure to empty the bladder completely so that there is an in- creasing amount of residual urine. The other usual Complica- tions of urinary obstruction also occur, including hydro-ureter and hydronephrosis, renal damage, urinary infection, and uremia. Diagnosis is established by palpation of the enlarged prostate upon digital rectal examination, and by visualization of the projecting lobes of the prostate as seen through the Cys- toscope. PROSTATECTOMY Surgical removal of the prostate (prostatectomy) results in the restoration of the ability to urinate normally. There are three methods of removing the prostate: Suprapubic transvesical pros- tatectomy, perineal prostatectomy and transurethral resection by means of the electrocautery knife through a cytoscope (resecto- scope). Each of these methods has its advantages and limitations. Preoperative Care. This is of great importance, for these men as a group are poor surgical risks. Furthermore, it is unsafe to re- lieve the urinary obstruction suddenly, as renal hemorrhages and failure to secrete urine (renal shutdown) may result, with fatal consequence. Release of the urinary back pressure (decompres- sion) is carried out gradually, either by means of an indwelling urethral catheter, or by a catheter introduced into the bladder through a suprapubic incision (suprapubic cystotomy), attached to a drainage apparatus which can be adjusted to various levels of pressure (Fig. 151). The duration of this period of decom- pressive drainage depends upon the particular condition and response of the patient, as judged by repeated estimations of his renal function (phenolsulphonephthalein excretion tests). The patient is judged ready for operation when renal function has made maximum improvement and the level of the blood urea has come down to normal. During this period fluids are forced, and antibiotic and chemotherapeutic agents are used to combat the infection of the urinary tract which nearly always complicates obstruction. 572 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS ſ U-tube To Urethral catheter FIGURE 151. Decompression apparatus. The bladder is gradually emptied and the intravesical pressure lowered as the reservoir and U tube are lowered to the level of the bladder. Before operation the shaving includes the abdominal, supra- pubic and perineal regions. The immediate preoperative prepara- tion is like that for any general or spinal anesthesia, depending on which type the surgeon has chosen. Suprapubic Prostatectomy. This operation is preferred by many urologic surgeons for patients in whom the prostatic en- largement is considerable and projects mainly into the bladder. General or spinal anesthesia is used. Through a low midline abdominal incision the bladder is exposed without entering the peritoneal cavity. The dome of the bladder is incised, bringing into view the base of the bladder; the projecting lobes of the en- larged prostate are easily seen surrounding the vesical orifice (outlet of the bladder). Another incision is made, this time through the lining of the bladder into the capsule of the prostate, SURGERY OF THE MALE GENITAL ORGANS 573 FIGURE 152. Suprapubic transvesical prostatectomy. and the lobes are enucleated by the surgeon's finger, care being taken not to tear the urethra or the region of the vesical orifice. It is customary during enucleation for the operator to ele- vate and steady the prostate from below by a finger in the rec- tum. The prostatic cavity is packed with gauze to control bleeding, an indwelling (mushroom) catheter is placed in the bladder through the wound, and the bladder and abdominal wall are closed in layers by sutures. On return of the patient to the ward the bladder catheter is immediately connected to an apparatus which exerts very mild suction (Connell apparatus) so that the urine is constantly re- moved, thus preventing distention of the bladder or extravasa- tion of urine into the wound. The gauze packing is removed forty- eight hours after operation. On about the sixth day after opera- tion an indwelling catheter is inserted and the suprapubic Catheter removed, permitting the abdominal wound to heal; When the wound is healed the urethral catheter is removed. 574 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS To balloon *—s ---> Urinar drainańe Foley catheter FIGURE 153. Connell suction apparatus. Inflation of the balloon of the Foley catheter prevents the catheter from slipping out of the bladder. The T tube must be secured in the position shown so that urine drops into the drainage bottle and is not drawn into the suction apparatus. The degree of suction is regulated by the rate of drip of of the oil; each drop traps and withdraws a small amount of air. Perineal Prostaffectomy. Division of the vas deferens (vasec- tomy) in the scrotum is often performed as a preliminary step to prostatectomy, for if the vas is not divided, bacteria may enter it as a result of the trauma incident to removal of the prostate; pre- liminary vasectomy thus prevents the occurrence of acute epi- didymitis, a painful and troublesome complication. This pro- cedure is easily carried out under local anesthesia the day before prostatectomy. For perineal prostectomy spinal anesthesia is satisfactory. The patient is placed in the lithotomy position, and an inverted U incision is made around the rectum. Dissection separates the rectum and urethra, and finally exposes the prostate, which is then removed. The perineal wound is sutured, a tube for drain- SURGERY OF THE MALE GENITAL ORGANS 575 %--> º §: { sº §§y Yºº Žº s \"\ SN N. § §). §§ 2 sº * S.W.) A SS º §§ ſº 3. . 2:=s § * š Y iº º ‘. . ſº E. º N {W $#3 º §: :EE Mºss * * * sy sº #sº 㺠º WSE º Žº º Nº.% Ż3% S. N \! §§§ ºAS \. º MºxºS N §º wº FIGURE 154. Perimcal prostatectomy. age being left in place; an indwelling urethral catheter is inserted for the purpose of keeping the bladder empty and the perimeal wound dry. On the patient's return to the ward the catheter is connected to the suction apparatus. The perineal tube is removed after two days; when the perineal wound is healed the urethral Catheter is removed. Transurethral Resection of the Prostate. For patients who have certain types of prostatic enlargement, notably moderate enlarge- ment of the median lobe with intrusion into the urethra, resec- tion by means of electrical cutting instruments through a modi- fied cystoscope (resectoscope) furnishes a highly satisfactory method of treatment. This procedure is particularly useful in elderly, poor-risk patients; the abdominal or perineal wound is avoided, and the period of confinement to bed and hospital is shortened. The preliminary preparation for this operation is the same as for the other types of prostatectomy, with the excep- tion of vasectomy which experience has shown to be unnecessary. 576 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS Eyepiece YZ}, Cúllin filame?: Enlarged prostate FIGURE 155. Transurethral prostatectomy. Following resection the control of hemorrhage is the most urgent problem. Despite electrocoagulation during the procedure there is often troublesome and persistent bleeding. A Foley catheter, which has at its tip an inflatable rubber bag, is used for the dual purpose of draining the bladder and maintaining hemostatic pressure upon the prostatic wound. Irrigation with physiologic saline is often necessary to remove clots of blood which may obstruct drainage. The catheter is kept in the bladder until the urine is no longer bloodstained, usually three to five days. A patient who has had a prostatectomy is subject to all the usual postoperative complications, in addition to the special hazards of hemorrhage into the bladder, urinary tract infection, and renal failure. Careful observation and measurement of the urinary output are essential, and frequent examination of the level of urea in the blood and tests of renal function must be made. Posfoperative Nursing Care. These elderly patients have usu- ally been in the hospital for some time in preparation for the operation so that they are familiar with the routine of the ward. SURGERY OF THE MALE GENITAL ORGANS 577 After operation, however, they are apt to become quite confused, whether or not they were ever disoriented before. It is common for them to have the urge to get out of bed. If sideboards are put on the bed, serious injury may be averted. Intravenous and subcutaneous fluids are given after opera- tion, and when the patient is in a state of shock or has had a spinal anesthesia, the foot of the bed is usually elevated on shock blocks. Fluids are forced as soon as possible on the day of opera- tion; a diet as tolerated is begun the second postoperative day. The catheter is connected either to straight drainage or to a suc- tion apparatus. The drainage tubing must be sterile and is there- fore replaced daily. Irrigations of the catheter are done occasion- ally by the surgeon but are done by the nurse only when the patient has had a transurethral resection. The surgeon changes the first dressing of the perineal wound; thereafter it is the re- sponsibility of the nurse to change the dressings as often as is necessary to keep the patient dry. The dressings are held in place with a modified T binder. In all perineal operations the incision passes very close to the rectum; if enema tubes or thermometers are passed into the rectum there is danger of puncturing the thin wall. After operation the patient is sometimes depressed. He may be ſrightened and bewildered by the numerous procedures that are necessary. An explanation of procedures given before they are started helps him to overcome his feeling of insecurity. He should be encouraged to talk and to ask questions and must receive intelligent answers. When there are questions which the nurse feels she cannot answer the surgeon's help should be sought. A gathering place, such as a sun porch, where ambulatory patients meet to talk and smoke, is valuable in raising morale. The patient will have more self-confidence when he sees that others in the same or later stages of treatment are able to accept their own situations with ease. Carcinomc of the Prostcute Cancer of the prostate is of common occurrence among elderly men. If the neoplasm becomes large enough to obstruct the out- flow of urine, the symptoms are the same as those of benign pros- tatic hypertrophy, and about 20 per cent of patients who have obstruction due to prostatic enlargement are found to have car. cinoma of the prostate. Many prostatic cancers are extremely 578 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS invasive, however, and often the presenting symptoms are the result of distant metastases of the prostatic tumor, to bone, brain, or elsewhere. The usual systemic manifestations of malignancy occur, including weight loss, weakness, loss of appetite, and anemia. On examination the prostate is found to be irregularly enlarged and stony hard in consistency. If the tumor has spread beyond the capsule of the gland the examiner can feel that it is fixed to the nearby structures, such as the rectum and base of the bladder. Diagnosis is confirmed by perineal exposure and biopsy of the tumor. For patients in whom the cancer is thought to be confined within the capsule of the prostate a radical perineal pros- tatectomy is the proper treatment. When the cancer has spread beyond the capsule, the treatment consists in removal of enough of the tumor by resectoscope to ensure adequate relief of urinary obstruction; this is followed by the implantation of radium or radon tubes for a carefully measured period, in an effort to eradicate the remaining tumor. It has been ſound that relief from the pain caused by the in- vasion of bone by prostatic cancer is obtained in many in- stances by castration, and that this procedure sometimes pro- duces regression of the malignant process. This discovery, in addition to offering hope of relief to many suffering patients, sheds new light upon the important problem of the causes of neoplastic disease. Tumors of the Testis Testicular neoplasms are not common, but the majority of them are malignant and usually occur in young men. Since the tumors arise from the germinal epithelium, many of them are teratomas–neoplasms which contain various tissues and resemble an abortive attempt at the production of a new individual. Painless enlargement of the testicle should lead to the imme. diate suspicion of neoplastic disease. Metastases occur early, and often the initial symptoms are due to distant extensions of the tumor. A positive diagnosis is made by biopsy and microscopic examination of the tissue; it is interesting, however, that in many patients having testicular tumors there is a large increase in the excretion of the gonadotropic hormone of the pituitary. This hormone is detected by the Aschheim-Zondek test, the same test used in determination of pregnancy. Treatment consists in removal of the tumor and testis, the sper. SURGERY OF THE MALE GENITAL ORGANS 579 matic Cord, and the associated lymph glands in the inguinal and retroperitoneal regions of the same side. If these glands have been invaded by the tumor the prognosis is poor. Radiation is to be used following operation. SUMMARY Except for injuries, most surgery of the male genital organs is concerned with congenital deſormities in the young and neo- plastic disease in the older patients. Both categories of patients need much reassurance and encouragement. Constant nursing attention to the management of urinary excretion is required, in addition to the therapy of the nearly always concomitant urinary tract infection. VOCABULARY REVIEW castration cryptorchidism varicocele gonad phimosis epididymitis androgen hypospadias prostatectomy hermaphrodite hydrocele transurethral SUGGESTED READING . Brendler, Herbert: Evaluation of Current Treatment of Prostatic Cancer. J. Urol., 68:734–743 (Oct.) 1952. . Buckley, George, and Kearns, John W.; Analysis of Results of Prostate Sur- gery in 866 Cases. J. Urol., 68:724–728 (Oct.) 1952. . Gross, Robert E., and Cresson, Samuel L.: Treatment of Epispadias: A Re- port of 18 Cases. J. Urol., 68:477–488 (Aug.) 1952. 4. Hayes, Basil A.: Retropubic Prostatectomy, Surgical Treatment. Am. J. Nursing, 50:435–437 (July) 1950. . Huggins, Charles: Endocrine Factors in Cancer. J. Urol., 68:875–884 (Dec.) 1952. Millsap, Juanita G.: Retropubic Prostatectomy, Nursing Care. Am. J. Nursing, 50:437–438 (July) 1950. Van Schoick, Mildred R., and Huggins, Charles: Carcinoma of the Prostate. Am. J. Nursing, 48:427–429 (July) 1948. Wright, Lucille, and Prince, Charles L.: Hypospadias, Nursing Care in the Surgical Repair. Am. J. Nursing, 46.688–689 (Oct.) 1946. Young, H. H.: Cure of Cancer of the Prostate by Radical Perineal Pros- tatectomy: History Literature and Statistics of Young's Operation. J. Urol., 53:188–252 (Jan.) 1945. l 2 3 8765 9. CHAPTER 48 Gynecology: Introduction ANATOMY AND PHYSIOLOGY OF THE FEMALE GENITAL TRACT Externcil Genifolic The organs comprising the female external genitalia are known collectively as the vulva. These consist of the labia majora, labia minora, clitoris, hymen, vestibule, and Bartholin's glands. The external openings of the urethra and Skene's ducts, although strictly speaking not a part of the external genitalia, are closely related to them and are described with them. Labia. The two labia majora make up the largest part of the external genitalia. Each is a rounded fold of fatty tissue covered on the outer surface with skin which in turn is covered with hair. The inner surfaces are smooth and composed of mucous membrane. In women who have not had children (nulliparae), the labia majora are in contact; after childbirth they remain separated. The two labia majora are connected posteriorly by a ſold of skin, and anteriorly they merge with the larger skin- covered pad of fat lying over the pubic bones and known as the mons veneris. The labia minora are two smaller folds of mucous membrane which lie within the labia majora. The anterior ends of these folds unite to form the prepuce of the clitoris. The posterior ends blend with the labia majora but are connected with each other by a fold of skin known as the fourchette. Clitoris. The clitoris is a rudimentary organ Corresponding to the penis in the male, situated at the anterior extremity of the labia minora. It is composed of erectile tissue containing nu- merous blood vessels. The body of the clitoris measures 2 to 3 centimeters in length. Meatus. The urethral orifice, or meatus, is situated approxi- mately 2 centimeters behind the clitoris. It is a circular opening measuring 4 to 5 millimeters in diameter and is lined with mucous membrane. It is important for the nurse to learn to recognize this opening since it is into the urethra that the catheter must be introduced when a patient is catheterized. 580 GYNECOLOGY: INTRODUCTION 581 Hymen. The hymen is a circular fold surrounding the entrance to the vagina. In virgins the opening is usually circular and ad- mits a fingertip although it may assume a variety of sizes and shapes. The hymen is generally ruptured at the first sexual inter- course; after childbirth all that remains is a few tags of mucous membrane called Carunculae myrtiformes. Bartholin's Glands. The vulvovaginal or Bartholin's glands are two in number and lie posteriorly on either side of the vagina, close to the outlet. These glands are important since they are frequently involved in gonorrheal infections which may lead to the formation of abscesses or cysts. Urefhrd. The urethra is an elastic tube the function of which is to empty the bladder of urine. The average length is 3 to 4 centi- meters and the normal caliber is approximately 4 millimeters. At the neck of the bladder the urethra is surrounded by the in- ternal sphincter muscle which controls urination. Throughout its entire course it lies close to the anterior vaginal wall. Perineum. The perineum is the region between the vagina and the rectum which forms the floor of the genital canal. The prin- cipal supporting structures in the perineum which may be in- jured during childbirth and which may need to be repaired sub- sequently are the levator ani muscles. Interncil Genifolic Vagina. The vagina is a musculomembranous tube extending from the vulva to the uterus and connecting the internal and ex- ternal genitalia. Normally, the vagina points upward and back- ward, making a right angle with the cervix. The vaginal mucous membrane is thrown up into a number of folds called rugae. Or- dinarily the vagina is collapsed, with the anterior and posterior walls in contact except where separated by the cervix. The upper part of the vagina which surrounds the cervix is known as the vaginal vault. The vagina possesses great capacity for distention as is shown by its dilatation to permit the passage of the head of the fetus during childbirth. The urethra lies close in front of the anterior third of the vaginal wall and the bladder lies beneath its upper two-thirds. The posterior part of the vaginal vault (posterior fornix) lies in close proximity to a peritoneal pocket known as the cul-de-sac of Douglas. This relation is important since pelvic abscesses are often drained by opening this cul-de-sac. Lower down, the rectum lies just behind the posterior vaginal 582 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS | Urefer Ovarian ves. t ?, * > * S \, . N * FIGURE I56. Female pelvic organs. wall, while the lowest part of the vagina lies within the perineum and is closely related to the perineal muscles. Uterus. The uterus is a hollow, thick-walled, pear-shaped organ composed of smooth muscle. The lower narrower portion is called the cervix and the upper broader portion is called the body or fundus. In a virgin the uterus averages 7% cm. in length, 5 cm. in width and 2% cm. in thickness, but after childbirth it is somewhat larger. Normally, the uterus leans anteriorly in the body with the fundus bent forward on the cervix. Its position varies in different individuals, and in the same individual with changes in position and with distention of the bladder. The lower part of the cervix extends into the vagina with the cervical canal opening at its center at the external os. The os is small and cir: cular in nulliparae, whereas in women who have borne children it is usually slitlike. The cervical canal is continuous with the cavity of the body of the uterus; the junction of these two canals GYNECOLOGY: INTRODUCTION 583 is known as the internal os. The length of the entire cavity from the external os to the top of the ſundus ranges from 7 to 9 cm. The upper part of the upper uterine cavity is Y-shaped; the two arms of the Y pierce the uterine wall and communicate with the fallopian tubes. The uterine wall consists of three layers: mucous membrane, which lines the cavity; smooth muscle, which makes up most of the wall; and peritoneum which covers most of the outer surface. Beneath the mucosa of the cervical canal are many branching glands which empty into the canal through small ducts and which secrete clear mucus. The mucous membrane which lines the uterine cavity and produces the menstrual flow is known as the endometrium. It is thicker than the cervical mucosa, measur- ing 2 to 5 mm. or more in thickness, and contains numerous glands which are simpler in structure than the cervical glands. The glands undergo a definite change during the menstrual cycle which is described more fully in the section on menstruation (p. 584). Fallopian Tubes. The fallopian tubes are two muscular canals 10 to 12% cm. long which are attached at their medial ends to the body of the uterus and are approximately the caliber of the aver- age lead pencil in size. Their function is to conduct the egg or ovum from the ovaries to the uterus. The tubes are covered by peritoneum which extends upward from the broad ligaments to surround them and which, between the broad ligaments and the tubes, is known as the mesosalpinx. Ovaries. The Ovaries are two oval bodies about the size of al- monds which lie on either side of the uterus on the posterior surface of the broad ligaments. Each ovary is attached along its anterior surface to the broad ligament by a ſold of peritoneum and to the uterus by the utero-ovarian ligament. The outer poles of the ovaries are attached to the pelvic wall by two folds known as the infundibulopelvic ligaments, through which the ovarian blood vessels reach the ovaries. The ovary has a tough, white, Wrinkled surface. Each consists of two parts, an inner medulla Which contains numerous blood vessels, and an outer cortex. Although the function of the medulla is unknown, the cortex con- tains the secreting structures of the ovary, the graafian follicles. In its earliest form each of these follicles is a very small, cystlike structure called the primordial follicle which contains an ovum. As the primordial follicle develops, it becomes larger, has a bigger Cavity, and a thicker wall composed of granulosa cells. The ovum 584 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS is situated in the wall of the graafian follicle, the cavity of which is filled with a fluid known as liquor folliculi, Containing the estrogenic hormone. This hormone is secreted by the granulosa cells. During active reproductive life several follicles “ripen” each month but usually only one ruptures, permitting the ovum to escape; the remainder of the ripe follicles then degenerate and may become cystic. Such cysts, which never become very large, are known as atretic follicles. After ovulation the follicle which has ruptured becomes filled with a blood clot and is known as a corpus hemorrhagicum. The granulosa cells lining the graafian follicle now change their character and become larger and yellow in color giving a yellow color to the whole structure, which is known as a corpus luteum. Like the graafian follicle this is an organ of internal secretion which secretes, in addition to the estrogenic hormone, another hormone known as progesterone. If pregnancy occurs, the corpus luteum persists and is known as the corpus luteum of pregnancy. If the ovum does not become im- planted, the corpus luteum degenerates rapidly, finally becom. ing a white scar known as a Corpus ablicans. The Menstrudl Cycle. Menstruation is the Cyclic bleeding from the endometrium or lining of the uterus. It begins at puberty and its function is to prepare the endometrium to receive and nourish the fertilized ovum or egg. In American girls menstruation usu ally begins between the ages of 11 and 16 years, although it is not unusual for it to begin at an earlier or later age. The average age in the United States is 13 years, whereas in the tropics it is considerably earlier, and in Europe a year or so later. The menses ordinarily occur at intervals of three to five weeks and the usual duration of the flow is from two to five days. Al- though the interval between menses is popularly regarded as twenty-eight days, actually the cycle is generally somewhat ir regular, and cycles of twenty-one or thirty-five days are not un- COIſl]][] OIl. Menstruation does not usually continue during pregnancy, al though it sometimes continues during the first few months. It generally ceases between the ages of 40 and 50 years, the cessation being known as the menopause, climacteric, or change of life, and coinciding with the Cessation of ovulation. In addition to the initiation and cessation of the menses, other very extensive changes occur in the body during puberty and the climacteric through the influence of the glands of internal secre. tion. Examples of these changes which occur at puberty are en- GYNECOLOGY: INTRODUCTION 585 Degenerating corpus luteum FIGURE 157. Diagram of menstrual cycle. The ovum matures (a), and is ex truded from the follicle (b) (ovulation). The corpus luteum forms (c) and the endometrium (at right) is ready for the implantation of a fertilized ovum. In the absence of fertilization, however, the ovum does not become implanted, the corpus luteum degenerates (d) and menstruation occurs. largement of the breasts and uterus and changes in the shape of the body and in the distribution of the hair. To aid in understanding the menstrual cycle it is necessary to consider the glands of internal secretion which regulate the menses. During the menstrual cycle definite periodic changes take place in the endometrium. When menstruation occurs the superficial endometrial layer, including glands and stroma, sloughs off and is carried out of the uterus with the menstrual flow, leaving only the basal layer. At the end of menstruation 586 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS the basal layer of the endometrium soon grows much thicker. At this stage the glands are straight and narrow and show no secretion. This phase in the endometrial cycle is known as the postmenstrual stage. Next, under the influence of the estrogenic hormone, which is secreted by the graafian follicles of the ovary, the glands become more dilated and tortuous, although as yet they show no secretion. This is known as the early interval or proliferative stage. On or about the fourteenth day after the beginning of the last menstruation, one, and sometimes more than one, of the graafian follicles in one or both ovaries ruptures and the ovum or ova are expelled. Within a few hours after the rupture of the follicle, secretion appears in the linings of the endometrial glands. The appearance of this secretion is usually interpreted as a sign that the follicle has ruptured, and is important in the study of sterility since it is an index of ovarian activity. It is produced by the ac- tion on the endometrium of a second ovarian hormone, called progesterone, which is secreted by the corpus luteum. In addition to the production of secretion in the glands of the endometrium, progesterone, with the help of the estrogenic hormone, which continues to be produced, causes extreme dilatation and tortuos ity in the endometrial glands. Progesterone does not act unless the endometrium has first been prepared by the estrogenic hor. mone. In the endometrial cycle this stage, from ovulation to the beginning of menstruation, is known as the secretory stage, and its latter portion, for about one week before menstruation, is called the premenstrual stage. While these changes in the endometrium are occurring, the ovum descends through the fallopian tube. If the fertilized ovum does not become implanted in the endometrium, menstruation occurs. The onset of menstruation coincides with a fall in the level of the estrogenic hormone in the blood, and is thought to be initiated by suppression of the activity of the anterior lobe of the pituitary gland (hypophysis), although the exact mechanism is not understood. The changes in the ovary which are responsible for the produc. tion of the estrogenic hormone and progesterone are in turn con- trolled by the secretions of the anterior lobe of the hypophysis. The first of these secretions, called follicle stimulating hormone (FSH), is responsible for the growth and maturation of the fol. licle. Under the influence of the second of these hypophyseal hor. mones, known as the luteinizing hormone (LH), the graafian fol. GYNECOLOGY: INTRODUCTION 587 licle ruptures, ovulation occurs, and the Corpus luteum is formed. A third hypophyseal hormone, LTH, stimulates the corpus luteum to secrete progesterone. It will thus be seen that not only the cyclic changes in the ovary but also the menstrual cycle are indirectly controlled by the hypophysis. These five hormones (FSH, LH, LTH, estrogen and proges- terone) occur in varying quantities in the female blood and urine depending on the age of the woman, the stage in the menstrual cycle when the specimens are obtained, and whether or not the woman is pregnant. One other hormone should be mentioned at this time. This is the chorionic gonadotropic hor- mone, also known as the anterior pituitary-like hormone (APL). Together with the estrogenic hormone this hormone occurs in large amounts in the urine of pregnant women. It is available commercially in concentrated form and has been used in the treatment of functional uterine bleeding. The Aschheim-Zondek, Friedman, and toad tests for pregnancy are based on the presence in the urine of the APL hormone. Commercial preparations of most of these hormones are avail- able under a confusing variety of trade names, and are in wide- spread use in treating symptoms caused or thought to be caused by endocrine imbalance in the female. Some of the preparations are effective when given by mouth but others must be injected into the tissues. In the treatment of menopausal symptoms such as nervousness and hot flushes by ſar the greatest success has been attained with the estrogenic hormone. This hormone has also been effective in curing gonorrheal vaginitis in children and Senile vaginitis in women past the menopause. In both instances it acts by making the lining of the vagina thicker and more re- sistant to inſection. Progesterone has been used successfully in threatened abortion, where it is supposed to relax the uterine muscle, and in certain types of prolonged vaginal bleeding due to a deficiency of this hormone. Other types of functional bleed- ing have been treated by combined therapy with estrogen and progesterone, with good results in some instances. In addition, sex hormone therapy has been recommended for a multitude of other conditions, often on dubious grounds and with extremely Variable results. PELVIC EXAMINATION This is, at best, an unpleasant experience for the patient. Much can be done by the nurse to make the examination easier for both 588 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS & 3%x, 43% % É § ſº É º Žºgº § § Sºº ; £º FIGURE 158. Bimanual pelvic examination. Insert shows palpation of uterus. the patient and the doctor. A sympathetic and reassuring attitude on the nurse's part helps the patient greatly. In addition, proper physical preparation of the patient for examination is very im: portant to the doctor and may mean the difference between a satisfactory and an unsatisfactory examination. A nurse should always be present during a pelvic examination. In addition to proper preparation of the patient, the nurse should try to have everything ready before the arrival of the gynecologist so the examination will not have to be interrupted. She should further assist by handing the doctor instruments as needed, and by focusing the spotlight while the cervix is being examined. Equipment. For a pelvic examination the nurse should prepare a tray or small table with the following equipment: good spot. light (if none is available, a flashlight may be used); liquid green soap or lubricating jelly; Small gauze sponges; one long Kelly clamp; bivalve vaginal specula, medium and small sizes; cotton GYNECOLOGY: INTRODUCTION 589 FIGURE 159. Catheterization tray for the female patient. applicators; two rubber gloves. If a cervical culture is to be taken there should be added: sterile applicators; culture tube; two microscopic slides and cover plates; unsterile normal saline with eyedropper. Since more cervical biopsies are being taken today than ever before, a sterile biopsy forceps should always be in- cluded with the equipment. Preparation of the Patient. The patient's bladder must be empty; therefore, if she is not to be catheterized, she should void before being draped for examination. Pelvic examinations are usually done with the patient in the lithotomy position (on the back, with thighs flexed and legs separated). Examination is most satisfactory if the patient can be placed on a regular examination table; however, if none is available or iſ she is a bed patient, she is prepared for examination in bed. If the patient is unable to help herself the nurse assists her to undress. All clothing is re- moved except shoes and stockings. Next, the patient is placed on the examining table with her hips at the edge of the table and her feet put into the stirrups. She is then draped with a sheet folded diagonally across the body with the opposite corners wrapped around her feet. If she is to be examined in bed, she is draped with the sheet in the same manner but the feet rest on the bed instead of in the stirrups; the knees are acutely flexed. The chest is covered with a towel. Occasionally, pelvic examinations are done with the patient in the knee-chest position. The Sims' or lateral position is seldom used at the present time. Cathererization. In the female it is difficult to obtain a voided specimen of urine which does not contain a few pus cells, even 590 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS ) N NA /* W #. tº g) y º * & & \;\º º % §§. | \º §§ §4% Žºgº. Rift º % & % S ſ § º º § FIGURE 160. Catheterization. though the genitalia were previously cleaned; therefore, many surgeons preſer a catheterized specimen of urine. Another reason for catheterization is inability of the patient to void; this condi tion is most frequently encountered following operation. Technic. The equipment necessary to carry out catheterization is shown in Figure 159. After the patient has been draped as for a pelvic examination with dressing towel and rubber under the hips, the dressing towel used to cover the tray is spread out at the foot of the bed and the tray is placed upon it. The catheter and forceps basins and the two enamel bowls are arranged near the patient. The cover of the sterile forceps basin is taken off, and with the sterile ſorceps three toothpick swabs are removed from the sterile jar. These are placed upright in the sterile basin. The lid of the catheter basin and the top of the Zephiran bottle are removed. After the glove has been put on the left hand, the perineum is exposed and the labia are separated. When the meatus is located the urethral orifice is cleaned by wiping it with GYNECOLOGY: INTRODUCTION 59 | a dry toothpick swab in circular motion outward to remove excess mucus. The second toothpick swab is dipped into the Zephi- ran and inserted slightly into the urethral orifice and rotated carefully. The circular outward motion is continued in cleaning the area for at least 2 cm. in diameter. This procedure is re- peated with the third toothpick swab as it was carried out with the second. While the left hand holds the labia steady to guard against contamination, the sterile catheter is picked up, with the right hand, at the junction of the rubber tubing and glass, and is inserted by following the curve of the urethra, first down- ward and then upward. The urine is drained into the bowl. The catheter should not be moved in any way after it has been in- serted. When the bladder is empty the rubber tubing is pinched and the catheter is gently withdrawn. The nurse should examine the catheter carefully before it is sterilized and again before it is inserted. A rubber catheter should be used for children and for pregnant and unconscious patients. SUMMARY A knowledge of the anatomy and physiology of the female generative tract is the basis for understanding its disorders. The menstrual cycle and pregnancy are controlled by ovarian activity which, in turn, is directed by hormones secreted by the hypoph- ysis. Routine gynecologic examination includes catheterization and bimanual pelvic examination. VOCABULARY REVIEW Bartholin's glands menopause ºlte?"uS fallopian tubes estrogen cervix follicle vaginal speculum endometrium corpus luteum meat uS ovary CHAPTER 49 Infections of the Female Genital Tract GONORRHEA Gonorrhea is a venereal infection caused by the gonococcus, and is the commonest cause of inflammation of the female genital tract. The causative organism is a biscuit-shaped gram-negative diplococcus which may be identified in pus from patients with the disease by staining or by culture. In the Gram stained smear the gonococci appear as groups of red diplococci inside the pus cells. Since cultures are frequently positive for the gonococcus when smears are negative, cultures as well as Smears are taken routinely in many clinics. The structures in the lower female genital tract which are in- volved in gonorrheal infections are the urethra, cervix, Bartho- lin's glands, and Skene's glands. The first two are most commonly infected. The disease is practically always contracted by direct sexual contact although rarely it is acquired innocently. The symptoms appear after an incubation period of three to eight days. The first of these are burning on urination, sometimes asso- ciated with frequency, and a purulent yellow discharge from the urethra or cervix or both. If the urethra is infected, the urethral meatus appears reddened, and a drop of pus may sometimes be expressed from it. If the cervix is infected, its surface appears a fiery red upon examination through a speculum, and there is a profuse purulent discharge from the cervical canal. In suspected cases of gonorrhea, smears and often cultures are made from both the urethra and the cervix. The vaginal mucosa is resistant to the gonococcus during reproductive liſe; gonor- rheal inflammation of the vagina, or vaginitis, occurs only in children or in women past the menopause. The infection in the urethra in adults is usually short-lived and subsides spontane- ously in a few days. However, if Skene's glands are involved, the infection there may persist for a long time and may require sur- gical intervention. Gonorrheal cervicitis is usually very persistent 592 INFECTIONS OF THE FEMALE GENITAL TRACT 593 because the gonococci lodge in the depths of the cervical glands, and if untreated the cervical discharge usually continues for many months. After the inſection has gone on for three or more weeks it becomes extremely difficult to demonstrate the gonococci even though the infection is still present. If one of Bartholin's glands is infected, it becomes swollen and painful and an abscess may develop. The infection in the gland sometimes becomes chronic, resulting in either a retention cyst or a chronically en- larged gland. Since Bartholin's glands are ordinarily not pal- pable, a palpable gland is presumptive proof of gonorrheal infection. Sometimes, when chronic infection of the lower genital tract persists for a long time, warty growths appear on the vulva, in the vagina, or on the cervix. These are known as condylomata acuminata or venereal warts, although they are not always of venereal origin. Complications If the gonorrheal infection spreads upward to involve the ſal- lopian tubes, inflammation of the tubes, or salpingitis, a serious complication, occurs. The gonococcus reaches the fallopian tube by way of the endometrium, which becomes temporarily in- flamed, but the infection here does not last long. When a fal- lopian tube becomes infected, it becomes swollen and red, and the lumen is filled with pus. Such a tube may be transformed into a retort-shaped sac of pus of considerable size (pyosalpinx), or an abscess made up of both tube and ovary may form (tubo- ovarian abscess). Usually in acute salpingitis the pelvic perito- neum becomes inflamed (pelvic peritonitis), and in a few cases the peritonitis spreads to involve the entire peritoneum (gen- eralized peritontis). Sometimes an abscess forms in the pelvis outside the fallopian tubes (pelvic abscess). Such an abscess usu- ally sinks into the Cul-de-sac of Douglas and, if not drained sur- gically, may rupture into the bladder or rectum. Patients with acute salpingitis usually appear moderately ill, and Complain primarily of lower abdominal pain. If acute Salpingitis is treated promptly and vigorously, it sometimes sub- sides completely, but more often the patient continues to com- plain of pain. The fallopian tubes usually have been so severely damaged that the lumina are obstructed and sterility results. Many patients continue to have a low grade infection of the fal- lopian tubes (chronic salpingitis), with persistent or recurrent 594 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS lower abdominal pain. Eventually, this condition may require surgical removal of one or both fallopian tubes. Trecitment Acute gonorrhea of the lower genital tract is always treated conservatively with the exception of abscess of Bartholin's glands, which must be drained. The therapy in use at present is a Com- bination of chemotherapy and local therapy. Chemotherapy Con- sists in treatment with one of the sulfa drugs or with penicillin given either intramuscularly or by mouth. In addition, hot douches (110–115° F.) of potassium permanganate 1 to 8000 or P.M.C. powder two or three times a day are usually given at very low pressures since there is danger of spreading the infection upward if high pressures are used. It is not necessary that such pa- tients remain in bed, but violent exercise is to be avoided. Sexual intercourse and alcohol are forbidden. After cessation of treat- ment, patients with gomorrhea are followed closely by the doctor. At least three negative cervical and urethral smears or cultures must be obtained before the patient can be pronounced cured. Before discharging the patient as cured, some gynecologists cau- terize the cervix to destroy any gonococci which may be lurking in the Cervical glands. Patients with acute gonorrheal salpingitis or gonorrheal peri- tonitis are acutely ill and are kept in bed at home or preferably in the hospital. They are given the same chemotherapy and douches as patients with lower tract disease, and are kept in low Fowler's position, which tends to keep the inſection localized in the pelvis. Care is taken to ensure an adequate fluid intake (2000 to 3000 cc. daily). Sedatives, such as 64 mg. codeine together with 0.6 gm. aspirin or 64 mg. Luminal every four hours are usually pre- scribed. An ice bag applied intermittently to the lower abdomen frequently gives relieſ from pain. Partial isolation of acute gonorrheal cases is necessary, and the bedpan, urinal, towels and bed linen should be carefully isolated. Rubber gloves are worn by the nurse when giving a douche or similar treatments. All concerned must be very careful not to get any pus into the eyes, as the gonococcus causes severe ophthalmia. The best precaution is prompt and thorough hand-scrubbing after each contact with the patient. Cauterization of the Cervix. This procedure is performed to eradicate chronic infection of the mucous glands of the cervix uteri. Since the cervix can be burned without pain, this operation INFECTIONS OF THE FEMALE GENITAL TRACT 595 FIGURE 161. Bilateral salpingectomy for hydrosalpinx. The left ovary and tube have already been removed. Dotted line indicates incision for re- moving diseased right tube. The right ovary will not be removed. may be done under either local or general anesthesia. If a general anesthetic is necessary, usually gas or sodium pentothal is used. A speculum is inserted and the vaginal mucosa protected from burns with damp sponges. The cervix is seized with a tenaculum and pulled down. The canal and the vaginal surface of the cervix are cauterized with the actual electric cautery, usually eight light, radial strokes like the spokes of a wheel being made. A variation of this operation, conization of the cervix, has been introduced. In this operation a conical piece of cervical tis- sue is removed with the electrosurgical unit, a special electrode being used. Following cauterization, or conization, the patients need only such nursing care as is required following anesthesia. Posterior Colpofomy with Drainage. A pelvic abscess frequently points behind the cervix in the cul-de-sac of Douglas. When this occurs, it is a simple process to drain the abscess through the vagina by making an opening into the cul-de-sac. Two cigarette drains or a long gauze pack is left in the abscess cavity with the ends protruding from the vagina. Postoperatively these patients are kept in high Fowler's posi- tion to expedite drainage from the abscess cavity. Beginning on the third or fourth day after operation the drains are shortened a 596 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS little each day and are completely removed by the seventh or eighth day after operation. After the drains are out, the patient is given douches or sitz baths. Sulſonamides or one of the antibiotics is generally given postoperatively. Salpingectomy: Salpingo-oophorectomy. In cases of chronic salpingitis in which lower abdominal pain persists after a fair trial of conservative therapy, at least for several months, the dis- eased fallopian tube or tubes must sometimes be removed. Occasionally it is found at operation that there is such extensive involvement of the ovary that it, too, must be removed. In young women who have bilateral salpingitis every effort is made to save at least one ovary, because removal of both ovaries produces a surgical menopause. If both fallopian tubes must be removed, a hysterectomy is usually carried out at the same time. If the pa tient is near the menopausal age it is not so important that the ovaries be preserved. Such operations are usually done under general anesthesia. The nursing care is the same as for other laparotomies. GONORRHEAL VULVOVAGINITIS In girls below the age of puberty, gonorrhea runs a completely different course from that in the adult. In childhood the disease is usually acquired by sleeping with infected adults or other in fected children, or from infected towels or washcloths. The type of gonorrhea which occurs in children is called gonorrheal vul vovaginitis, because the disease is usually limited to the vulva and vagina. Gonorrheal vulvovaginitis is highly contagious and often spreads through pediatric wards and orphanages. For this rea son, strict isolation of infected children is imperative to prevent the spread of the disease. The symptoms appear three to eight days after exposure. There is a purulent vaginal discharge, and on examination the vulva and vaginal orifice are seen to be reddened and covered with pus. Inspection of the vagina through a Kelly Cystoscope shows a simi lar inflammation of the entire vaginal mucosa and of the surface of the cervix. The vaginal smear and culture are positive for gono COCCUIS. Treatment. As in adults, penicillin therapy is most successful, and has replaced other forms of therapy. CERVICITIS Chronic inflammation of the cervix commonly follows child birth injury or gonorrheal cervicitis. Among the common mani INFECTIONS OF THE FEMALE GENITAL TRACT 597 festations of cervicitis are cervical erosions which appear as red, granular areas surrounding the external os. Actually most so- called lesions are not erosions or ulcers at all, but areas of in- flammation, or eversions (turning out of the lining of the Cer- vical canal on the surface of the cervix). Eversions of the cervix give rise to no symptoms unless inflammation is present. The symptom common to all types of inflammation of the cervix is a white vaginal discharge, leukorrhea, which varies considerably in quantity and appearance. The treatment of erosions and eversions consists of douches, local applications of antiseptics, and cauterization or conization of the cervix. Many patients respond to douches of powder men- thol compound or boric acid and alum powders, or some similar preparation, given twice a day. Cauterization of the cervix with silver nitrate or some similar drug is sometimes done. In cases which do not respond to douches, the leukorrhea usually clears up following cauterization with the actual cautery, or conization with the electrosurgical unit. Lacerations of the cervix are usually the result of childbirth. They may be either unilateral or bilateral, or stellate (star- shaped). Lacerations not immediately repaired after childbirth, in healing leave one or more clefts in the cervix. Usually they are complicated by chronic infection and give rise to leukorrhea. The original treatment of severe chronic cervicitis following childbirth was amputation or operative repair of the cervix. Since the introduction of cauterization by Hunner it has been found that in most cases this procedure clears up the cervicitis and the leukorrhea, making amputation unnecessary. Amputation should not be done during active sexual life since abortion or difficult labor often follows. PUERPERAL AND POSTABORTAL INFECTIONS The majority of these inſections are due to the streptococcus, although they are sometimes caused by other organisms. All of them have one thing in common, that is, they generally produce cellulitis, an inflammatory reaction characterized by brawny thickening of the soft tissues of the pelvis. Such infections some- times follow instrumentation such as curettage of the uterus in nonpregnant women; they are rather common following radia- tion for pelvic cancer. Acute puerperal inſections are seldom seen by the gynecologist, but in their later states they come within the realm of gynecology. Postabortal infections are among the most serious the gynecolo- 598 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS gist must treat. Most of them follow attempted criminal abor- tions, in the course of which virulent bacteria are introduced into the uterine cavity. Sometimes such infections follow spontaneous, and occasionally therapeutic, abortions. They may involve the endometrium only, or may extend into and through the uterine wall and into the broad ligaments, in which case the infection is much more serious. The inſection spreads, not along the uterine and tubal mucosa as in the case of gonorrhea, but through the veins and lymphatics of the uterine wall and broad ligaments where a thrombophlebitis and lymphangitis are produced. The thrombophlebitis may spread into the femoral vein, causing phlegmasia alba dolens (milk leg). If the fallopian tubes are in- ſected, the infection attacks them from without by way of the broad ligaments. The tubal mucosa is affected last, if at all, and for this reason, if the patient recovers, she is less likely to be sterile than if she had had gonococcal salpingitis. Abscesses of the broad ligaments and pelvic or generalized peritonitis may com- plicate the picture, particularly if instrumental perforation of the uterus has occurred. Infection of the blood stream is Common. Patients with postabortal inſections usually appear quite ill, with high fever and, if there is a blood stream infection, chills. There is generally vaginal bleeding or foul-smelling vaginal dis- charge. If there has been much loss of blood, the patient is prob- ably very anemic. On examination there is usually tenderness and sometimes there are signs of peritonitis over the lower or even the entire abdomen. Treatment. These patients should be hospitalized and require careful, constant nursing. They are kept in high Fowler's position to prevent the inſection from spreading and to improve the drain- age from the uterus. An ice bag applied intermittently to the lower abdomen helps to make the patient comfortable. Sedatives such as codeine and aspirin or codeine and Luminal are required. The sulfonamides and antibiotics are given separately or to: gether. It is important that the patient have sufficient fluids, and an intake of 2000 to 3000 cc. a day should be assured; a record of the intake and output is kept. If the patient is vomiting or is unable to take fluids by mouth, intravenous fluids are given. If the patient is anemic, transfusions are necessary until the hemo- globin has reached a satisfactory level. Enemas and strong Cathar- tics sometimes stir up the pelvic infection and should not be given unless absolutely necessary; mild laxatives such as mineral oil or cascara are preferable. If femoral thrombophlebitis is pres- INFECTIONS OF THE FEMALE GENITAL TRACT 599 ent, the leg is elevated and heparin or Dicumarol therapy is usu- ally started. Under no circumstances is such a leg massaged. Hot gallon douches are usually started ten days or more after abor- tion or delivery. Acute puerperal and postabortal infections are, with an occa- sional exception, always treated conservatively, but subacute or chronic infections may require operation. This is true of abscess of the broad ligaments which persists after several weeks of ther- apy. Such an abscess is drained by making a low McBurney in- cision and placing cigarette drains close to the abscess without opening the peritoneum. In patients who have salpingitis complicating postabortal or puerperal infections and who continue to complain of lower ab- dominal or pelvic pain after long courses of conservative treat- ment, removal of the inflamed fallopian tubes may be necessary. The technic and nursing care for this operation are the same as for gonorrheal salpingitis (p. 594). TUBERCULOSIS OF THE GENITALIA This is nearly always a local manifestation of a generalized tuberculous infection, with the primary infection located else- where in the body. Pelvic tuberculosis may affect the cervix, the endometrium, the fallopian tubes, or the ovaries. Usually the primary lesion lies in the lung or the intestinal tract, with the tubercle bacillus reaching the pelvis by way of the blood stream. Endometritis occurs in about three fourths of the cases of pelvic tuberculosis and salpingitis in almost every case. Tuberculosis is the cause of 5 per cent of all cases of salpingitis. In one third of the cases of pelvic tuberculosis the ovaries as well as the tubes are involved. Tuberculosis of the cervix is rare. The ſallopian tubes may be infected as the result of a gen- eralized tuberculous peritonitis, but more often the tubercle bacilli are carried to the fallopian tubes through the blood stream from a distant focus. Tuberculous peritonitis may be sec- ondary to, as well as the cause of, the salpingitis. Peritonitis is of two forms, the dry ſorm in which the intestines are matted to- gether by dense adhesions, and the wet form in which the abdo- men is distended with clear yellow fluid. Genital tuberculosis is notoriously hard to diagnose unless the patient has obvious tu- berculosis elsewhere. Treatment. When tuberculosis of the cervix, the endometrium or the fallopian tubes is proved by pathologic examination, the 600 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS uterus, tubes, and ovaries are removed if possible. Streptomycin and para-aminosalicylic acid are given after operation. Nursing Care. In general the nursing care is the same as for patients aſter other laparotomies. In addition the general sup- portive care ordered for tuberculous patients, including high caloric diet and rest in bed for a period of several months, is given. It is usually advisable to transfer the patients when Con- valescent to a tuberculosis sanatorium for further care. GRANULOMA INGUINALE This venereal disease is caused by a nonmotile, gram-negative, encapsulated bacillus. The disease is more common in Negroes and is fairly widespread in the southern United States. The disease is essentially a superficial progressive ulceration of the vulvo-inguinal region which may also involve the lower abdomen and buttocks. The ulcerated areas are covered with red granulation tissue and there is usually considerable purulent discharge. The disease may cause extreme enlargement or ele phantiasis of the vulva. The lesions heal with the formation of scar tissue. The disease usually runs a chronic course of many months' or years' duration. Treatment. Except when elephantiasis is present, the treatment of this disease is medical and consists in intravenous injections of tartar emetic (antimony and potassium tartrate). In advanced cases of elephantiasis, excision of the vulva (vulvectomy) must sometimes be done. This condition is not highly infectious and the patient need not be isolated. LYMPHOGRANULOMA VENEREUM This venereal disease is most common in the Negro, occurring only occasionally in the white race. It is caused by a filtrable virus and is primarily a chronic infection of the lymphatics, characteristically causing inguinal adenitis in men and rectal stricture in women. Indolent ulcers of the vulva and vagina fre quently occur, and there is usually scar tissue at the borders of the ulcers. The ulceration may destroy the urethra in part or entirely, resulting in urethral stricture in the former case and urinary incontinence in the latter. If the lymphatics of the vulva become involved, a chronic lymphedema, producing great en- largement or elephantiasis of the vulva, may result. Inguinal adenitis occurs in women as well as in men, and the inguinal glands may suppurate; such suppurating glands are known as INFECTIONS OF THE FEMALE GENITAL TRACT 60 | buboes. The disease usually runs a chronic course and tends to burn itself out after a number of years. The diagnosis is made by the appearance of the lesions and by means of an intradermal test, the Frei test. Treatment. Treatment in the early stages has been more satis- factory since aureomycin therapy has been introduced. Should the glands suppurate, the buboes are either incised and drained, or the pus is aspirated repeatedly with a syringe and needle, until the adenitis subsides. The surgical treatment of rectal stricture is discussed in Chapter 28, page 324. If elephantiasis of the vulva is extensive, a vulvectomy may be required. Urinary in- continence is treated by transplanting a loop of fascia from the sheath of the rectus abdominis muscle around the urethra. SPECIAL NURSING PROCEDURES IN PELVIC |NFLAMMATORY DISEASE Douches Solutions. Those commonly used include: potassium per- manganate 1:8000; P.M.C. (powder menthol compound); salt and Soda; and boric acid and alum. For cleaning purposes and as routine treatment the solution is 105° F. When a hot gallon douche is ordered (usually for pelvic inflammation) the tempera- ture is from 110 to 115° F. Equipment. This consists of: irrigation stand or tree; irrigator (rubber bag, enamel can or glass reservoir) with rubber tubing (approximately 36 inches long) with clamp attached; douche nozzle, sterile (sometimes after plastic vaginal operations the surgeon will order the douche given with a rubber catheter); douche pan or bedpan; small rubber sheet and towel; leggings or sheet; two finger cots or a rubber glove. For convenience the equipment is collected on a tray and in- spected for secure fastenings and intact nozzle. Sometimes the surgeon orders a sterile douche; otherwise, it is sufficient to have the equipment clean and only the nozzle sterile. The equipment is brought to the bedside and the irrigation pole put into posi- tion at the foot of the bed. Preparation of the Patient. The patient's cooperation will be Increased if she understands the treatment. The sheet is used to cover the patient; the bedcovers are fan-folded to the foot of the bed. For an effective douche the patient should be flat on her back with only one pillow under her head, knees bent, and the Soles of her feet planted firmly on the mattress. She is draped as 602 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS - * • • ~y. 4% * * * & zºº/ .35 § º , , , , ; , Yº - . . S = - Vº * ſ / * lºvel of containar Es 6in. abova mattrass -: § § § º | &\\ §§§ #. * §§ - §#|{{{\#|Šišilišš ºilº iº i º § §§§ §é §§ ºpiºiº # $ tºtăş$8. §§§§till §§§§§§§ HºHºº | ºftºlºſſățălțiilºſº FIGURE 162. Technic for administering a douche (vaginal irrigation). for a pelvic examination, with the sheet laid diagonally across her and the corners wrapped around her feet. The small rubber sheet, covered with a towel, is placed under the buttocks to pro- tect the bed. The patient will be more comfortable iſ a folded treatment towel is placed on the rear edge of the douche pan before it is put under her. Technic. After another inspection for cracks and rough edges, the nozzle is attached to the tubing without contaminating it. The finger cots are used on the thumb and forefinger of the leſt hand and these fingers used to separate the labia. Air is expelled INFECTIONS OF THE FEMALE GENITAL TRACT 603 from the tubing by allowing some of the solution to run through it. Then the tubing is clamped off and the nozzle gently inserted into the vagina for about 2 inches; an upward and backward motion is used. The clamp is released and the solution allowed to flow slowly. The irrigator should be not higher than 18 inches above the bed. At the conclusion of the douche the nozzle is re- moved, disconnected, and placed in a basin. The patient is left on the pan for a few minutes to allow all of the fluid to drain out of the vagina. After-Care. If the patient has had a perineal operation the perineum is carefully dried with sterile cotton pledgets and a sterile perineal pad is applied. After the patient has been made comfortable the equipment is removed, washed and boiled. Charting of the treatment includes time, solution, solution strength, amount, character of return flow, and the patient's reaction should she have one. SUMMARY Venereal disease, tuberculosis and criminal abortions cause most of the infections of the female genital tract. As in other infections, treatment is directed at supplementing nature's own defenses. Antibiotic and chemotherapeutic agents are extremely valuable. Surgical procedures are reserved for complications. VOCABULARY REVIEW gonorrhea vulvovaginitis lymphogranuloma colpotomy cervicitis cauterization salpingectomy douche SUGGESTED READING 1. Bundesen, H. N., Plotke, F., and Eisenberg, H.: Psychosomatic Approach to Venereal Disease Control; Chronic Gonorrhea Repeaters. Am. J. Pub. Health, 39:1535–1540 (Dec.) 1949. 2. Buxton, C. L.: Treatment of Leukoplakia and Kraurosis Vulvae. Geriatrics, 5:142-146 (May-June) 1950. 3. Hirst, Donald V.: Dangers of Improper Vaginal Douching. Am. J. Obst. & Gynec., 64:179–183 (July) 1952. 4. Smiley, William L., and Bozeman, Wilfred: Uterine Bleeding in Pelvic In- flammatory Disease. Am. J. Obst. & Gynec., 64:197–199 (July) 1952. 5. Stokes, John Hinchman, and Taylor, Jane Barbara: Dermatology and Ven- ereology for Nurses. Philadelphia, W. B. Saunders Co., 1948. 6. TeLinde, Richard W.: Operative Gynecology. 2nd Ed. Philadelphia, J. B. Lippincott Co., 1953. Wharton, Lawrence R.: Gynecology Including Female Urology. Phila- delphia, W. B. Saunders Co., 1943. CHAPTER 50 Congenital Deformities; Sferility; Disorders Due to Pregnancy CONGENITAL DEFORMITIES In embryonic life the fallopian tubes, uterus, cervix uteri and upper vagina are ſormed from the müllerian ducts, two tubular structures which normally join to form a single canal, the utero- vaginal canal. This becomes the uterus and upper vagina. The lower part of the vagina is formed by an infolding of the surface of the body of the embryo, which dips in to meet the uterovaginal Canal. Deformities of the Vagind cºnd Hymen Absence. Congenital absence of the vagina is usually asso- ciated with absence or rudimentary development of the uterus and fallopian tubes. Women having this anomaly never men- struate, of course, but the condition is otherwise asymptomatic. If such a patient wishes to lead a normal sex life, an artificial vagina must be made. This is done by making an opening in the skin at the site of the normal vaginal outlet and lining it with mucous membrane. One method of providing mucous membrane is to bring down a loop of isolated small intestine so that the intestinal mucosa lines the vagina. Another method is to line the artificial vagina with flaps of mucous membrane from the labia. In this case a sterile mold, the size of the desired vagina, is left in place until healing occurs. A modification of this method is to make an artificial cavity, insert the mold, and let the epithelium grow in from the surface to form a liming. In the method most recently described the patient herselſ makes pressure with a spe- cial glass rod against the perineum daily until a vagina of the proper size is formed. The care of a patient who has had an artificial vagina made is the same as for other vaginal cases. A retention catheter is usu- ally left in the bladder and care must be taken to see that it is draining properly. Care must also be taken lest the mold slip out of place. It is removed approximately two weeks after opera- 604 STERILITY; DISORDERS DUE TO PREGNANCY 605 tion, when the patient is instructed to wear it until the vagina heals completely. Imperforate Hymen. This is a rare Congenital anomaly which results from the failure of the upper and lower parts of the vagina to become connected in fetal life. Usually this abnormality is not noticed until puberty, when external vaginal bleeding fails to occur. The menstrual flow is dammed back and accumulates in the vagina; this is called hematocolpos. When the accumula- tion occurs in the uterine cavity the condition is termed hemato- metra and when in the fallopian tubes, hematosalpinx. In hematocolpos the retained blood causes the hymen to bulge out- ward. The treatment is incision of the hymen and drainage of the accumulated blood. Double Vagina. A double vagina results from failure of the septum between the vaginal portion of the müllerian ducts to disappear. It is often associated with double cervix and uterus and usually does not require surgical treatment. Deformities of the Uferus . These anomalies are the result of various degrees of failure of the upper müllerian ducts to fuse. There are several such anomalies including didelphic uterus (double uterus and double cervix), bicornuate uterus (upper uterus divided into two lateral horns), and septate uterus (uterine cavity divided by a longi- tudinal septum). These anomalies generally do not require surgical treatment unless they are Complicated by pregnancy or produce repeated abortion. If pregnancy occurs in one horn of a bicornuate uterus, normal delivery is impossible and the patient has symptoms like those of a tubal pregnancy. The treatment consists of excision of the pregnant horn. The nursing care is the same as for other pa- tients with pelvic laparotomies. STERILITY Failure to conceive may be due to either male or female dis- ability. In the female, obstruction of the ſallopian tubes, most often caused by inflammation of the tubes, is the commonest Cause of sterility. Obstruction of the cervical canal, either con- genital or acquired, retroposition of the uterus, and tumors of the body of the uterus are also causes. Ovulation occurs about fourteen days after the beginning of the previous menstrual period; the fertile period extends ap- 606 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS proximately from the twelfth to the sixteenth day of the cycle. It is important that patients understand the span of this fertile period since the other days of the cycle are relatively sterile. It has been shown by Hartman that a few patients sometimes men- struate without ovulating; such patients, of Course, are sterile while this condition exists. Other endocrine disturbances, such as ‘hypothyroidism and functional amenorrhea, may also cause sterility. Examinations. The couple with sterility must be carefully studied according to plan. First the wife is examined to rule out obvious pelvic disease. Next the husband's semen is examined either directly or by the Huhner test. This consists in examina- tion of material from the wiſe's vagina or cervical Canal shortly after intercourse. It should show many motile spermatozoa. If the examination of the husband is satisfactory, a Rubin's test is done on the wife to determine whether the ſallopian tubes are patent. This may be done in the doctor's office, but should be carried out with the patient under anesthesia in the hospital iſ it is thought wise to dilate the cervix at the same time. It is de- sirable to do a Rubin's test in the second half of the menstrual cycle, so that a biopsy of the endometrium may be performed at the same time, to rule out anovulatory menstruation; absence of secretion in endometrial glands is evidence of this condition. If the patient has retroposition of the uterus, a Smith-Hodge pessary may be inserted to hold the uterus in position. A basal metabolic rate determination to rule out hypothyroidism should be carried out on all patients who complain of sterility. In patients with sterility who need abdominal surgery for some other condition a retrograde Rubin test may be done. Salpingog. raphy (x-ray examination of the fallopian tubes after injection of Lipiodol or other opaque medium) is a useful procedure. Rubin’s Test. This test can be carried out in the office without anesthesia, or in the hospital with the patient under anesthesia. After routine clean-up, with the patient in the lithotomy posi- tion, the insufflation apparatus is first tested for leaks. The cervix is then seized with a tenaculum and the cannula of the insuf- flation apparatus inserted into the cervical canal with the rubber nipple against the cervix. The vagina is filled with sterile water to detect improper escape of air back around the cannula and the gas is allowed to run slowly into the tubing. The rate of flow of the gas is estimated by the number of bubbles which pass through the cylinder. The pressure of the gas is noted on the -: - - - aw f - E $: - s: $9 # º *A 'o º - iko - ſūrºll : - o s - t F----. *. º-Yº EYW---ºriº +--- s: \ 7, s: =#’ - ***E. J.E. T - wº-ºº: *tz | *- : •ºw- - i | $: Łºś :*: «- - :*: | | ) t ŠE } S = e- ºr -4 s: 3 % §§§ º: Śāj: - - o 535:3 †s sºlstºº NS: o --- - * §§§ {s}. , '4' | § §§§ }} E. § 3. : N 2% §§§ Sºlº tri- ZT”. §§§% *** - - |Šºššºt tº **śńiº N ź § º-º-º: sº .” Y % * .S.'. *, * §§§,2}} : % §§§ ºš. . . " $: - § §§§: > . &: * 3's sº ſº." & } lº * 'S A. * Sy $3 §§§§ *::,' ' ' (ºr * e - :-5 °. 'º', " . -: *k, rir x - - t - * - - * * - > #. t’ ”, “ . t 3. r S-S- - t §§§ ...? r # + t * *S • * .r - f . - §§: * s -" . E} j^, P. ::=– º . ~ * -: * * - | F. Hº: --- * ~ * w = * * ----------- $º. tº , ", . Sº. > ~-º b: - * tº 'ºt º' § $3;S É zº- ºf cºrv * ~ * t §º Š: =====º ºl ^. “, º: ºr--º- §§§ i is ºft E*- ºs-e- * s' s - Fº Sº :*Šº º • ..." §º: - *...’s “.. ... i **** *SSS § * Rºº. *-> * W. $ {. - £S of ºśed | i FIGURE 163. Rubin's test (tubal insufflation). The apparatus measures and re- cords the pressure of the air which is pumped into the uterus. If one or both tubes are patent the air pressure does not continue to rise, as the air escapes into the peritoneal cavity. 607 608 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS manometer and is allowed to increase up to 200 mm. of mer- cury. A fall in pressure indicates patent fallopian tubes. An assistant listens over the abdomen with a stethoscope, and a bub- bling or whistling sound confirms the fact that gas is entering the peritoneal cavity. Treatment. A number of procedures are helpful in treating sterility. If a Rubin's test is unsatisfactory on first attempt it is worth while to repeat it several times, as sometimes a later test is successful. If the basal metabolic rate is low, thyroid extract is given. Rest, and vitamins C and E are sometimes helpful in treat- ing both the sterile husband and wife. If there is cervical stenosis, the cervix should be dilated. If the patient has an anovulatory cycle, pregnant mare's serum (gonadotropin) may be given intra- venously when ovulation is due and may cause ovulation in Some cases. Plastic operations on the ſallopian tubes by the abdominal route in women in whom the fallopian tubes are obstructed lead to pregnancy in a small number of cases (approximately 5 per cent). The results are so poor that these operations are seldom done except in patients who need abdominal operation for some other condition. RELAXATION AND MALPOSITION OF THE FEMALE GENITALIA Relaxed Vagincil Outlet Many women who have had one or more children have relaxa- tion of the vaginal outlet. If the bladder protrudes into the vagina, the condition is known as cystocele. If the floor of the urethra also protrudes into the vagina, the condition is known as urethrocele. Patients with cystocele and urethrocele may have no symptoms, but many complain of a severe bearing-down sensation in the vagina and a feeling “as if everything were about to drop out.” Because of stretching of the floor of the urethra many of these women have partial urinary incon- tinence when they laugh, cough, or sneeze. When the fascia of the posterior vaginal wall is broken down by childbirth, a herniation of the rectum into the vagina results. This is known as rectocele. Some patients with rectocele are asymptomatic; others complain of a bearing-down sensation and many of them are constipated. Treatment. Patients with relaxation of the vaginal outlet with or without cystocele and rectocele need no treatment if they are STERILITY; DISORDERS DUE TO PREGNANCY 609 Sº FIGURE 164. I, Anteflexion; 2, retroposition; 3, uterus held in normal position by pessary; 4, Smith-Hodge pessary. asymptomatic; however, the symptoms are often so severe that they are incapacitated and something must be done to correct the condition. If a cystocele exists, it is repaired by means of an operation known as an anterior colporrhaphy. In this operation the bladder is pushed back into place from below and the fascia tor ani muscles are sewed together again so as to reconstruct of the anterior vaginal wall is reconstructed, so that the bladder cannot again prolapse into the vagina. If the patient has relaxa- tion of the vaginal outlet with a rectocele, it is repaired by re- placing the rectum and reconstructing the fascia of the posterior vaginal wall. In the course of this operation the separated leva- the perineum. Uterine Displacements Prolapse. In association with the relaxed outlet, many women have displacement of the uterus downward into the vagina. This is the result of stretching of the ligaments of the uterus during pregnancy and childbirth, and the condition is known as descensus or prolapse of the uterus. It is spoken of as partial or complete, depending on how far down the uterus comes. If the 610 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS uterus protrudes completely from the vaginal outlet, the condi- tion is called complete prolapse or third degree descensus. Pro- lapse of the uterus is treated by an operation which is performed through the vagina, but if the prolapsed uterus is abnormal it is removed through the vagina (vaginal hysterectomy). Anteflexion. In addition to descensus of the uterus, there are a number of other abnormal positions which the uterus may assume. Sometimes the fundus of the uterus is bent forward on the cervix at a very acute angle; this condition is a Congenital abnormality. Patients having acute anteflexion may be asympto- matic but many of them suffer from severe dysmemorrhea, which is treated by dilating the cervical canal under anesthesia. This procedure usually relieves the patient's symptoms temporarily. Anteflexion is usually cured by childbirth. Retroposition. In about 20 per cent of women the uterus is dis- placed backward. Retroposition of the uterus may be congenital or may be the result of stretching of the uterine ligaments during pregnancy. Many patients with retroposition of the uterus have no symptoms; in such cases no treatment is necessary. Some, how- ever, complain of severe backache which is worse when they are on their feet. Many also complain of severe dysmenorrhea. In addition, in some instances, retroposition of the uterus is thought to be responsible for sterility. Treatment. Patients who have severe symptoms are treated, when possible, by manipulation and replacement of the uterus during pelvic examination. The uterus is then held in place by inserting a Smith-Hodge pessary into the vagina. The patient who wears a pessary must take a daily douche and the pessary must be changed at intervals of two months, to prevent irritation of the vaginal wall. The Smith-Hodge pessary is used chiefly as a therapeutic test to determine whether the patient's symptoms will be relieved by replacement of the uterus. Such a test should always be made before a suspension operation is done. There are several different operations designed to suspend a uterus which is in retroposition and most of them are based on some procedure which shortens the round ligaments. The most commonly perſormed operation is the modified Gilliam suspension in which the round ligaments are sutured to the fascia of the rectus abdominis muscles, a procedure which is gen- erally successful in Correcting retroposition. The nursing care ſollowing this operation is the same as for other gynecologic laparotomies. STERILITY; DISORDERS DUE TO PREGNANCY 611 Tubosovarian Ampullar łubal ==# SEE? §% & Broad licement- forming Secondar abdomina Abdominal Sº AP e c + U on FIGURE 165. Various sites in which extra uterine pregnancies have occurred. A tubal pregnancy which has just ruptured is shown on the right side. Fistulcis Vesicovaginal Fistula; Rectovaginal Fistula. Sometimes during childbirth, in the course of a pelvic operation, or following radia- tion therapy for pelvic disease, the bladder or rectum is injured So that a communication between one of these organs and the vagina results. Such an opening is known as a vesicovaginal or a rectovaginal fistula, and is accompanied by leakage of urine or ſeces into the vagina. Treatment. Cure of these fistulas is accomplished by procedures designed to close the opening into the bladder or rectum and cover it with normal vaginal wall. After operation an indwelling catheter is placed in the bladder in order to keep the bladder empty and the wound dry. The nursing care is the same as aſter vaginal operations. The catheter must be kept open and draining at all times since blocking of the catheter may result in recur- rence of the fistula. EXTRA-UTERINE PREGNANCY Occasionally a fertilized ovum becomes implanted in the ovary or ſallopian tube instead of in the uterus as normally occurs. Such an abnormal pregnancy is known as an ectopic or extra- uterine pregnancy, and is caused by an obstruction to the passage of the fertilized ovum through the fallopian tube. As the ſer- tilized ovum grows and enlarges in the fallopian tube, the thin tubal wall becomes tightly stretched. One of two things happens: the wall of the fallopian tube ruptures into the abdominal cavity, or the embryo is extruded into the lumen of the tube and out 612 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS through the fimbriated end. This latter is known as a tubal abor- tion, and either rupture or tubal abortion is accompanied by a severe hemorrhage into the peritoneal cavity. The typical history of a woman with extra-uterine pregnancy is as follows: she misses a menstrual period and perhaps thinks she is pregnant. Several days or weeks later she notices vaginal bleeding which is usually not very profuse. This is followed by a sudden severe pain in the lower abdomen, after which the pa. tient frequently faints. The severe pain and fainting are caused by the sudden hemorrhage into the peritoneal cavity as the tubal pregnancy ruptures or aborts. Tubal pregnancy is difficult to diagnose before rupture occurs. The diagnosis of tubal pregnancy is always considered when a patient who has missed a period complains of pain in the abdomen. The discovery of a soft mass on one side of the uterus makes the diagnosis more certain. In doubtful cases the diagnosis can often be made by means of Culdoscopy. The Culdoscope is an instrument resembling a cystoscope; it is intro- duced through the vagina, behind the cervix, into the peritoneal cavity. The pelvic organs can usually be clearly visualized. Ectopic pregnancy is easy to diagnose after rupture, when the patient presents the typical picture of posthemorrhagic shock. In addition, the abdomen is extremely tender because of the blood in the peritoneal cavity and the umbilicus may be blue in Color from the same cause. Treatment. Ectopic pregnancy is a surgical emergency since the patient may die from hemorrhage if she is not treated promptly. A woman with an ectopic pregnancy which has not ruptured should be operated on before rupture occurs. When a patient with a ruptured ectopic pregnancy reaches the hospital, she is treated first for shock. As soon as she has been given a transfusion and her condition has improved enough to risk surgery, a laparotomy is done and the involved fallopian tube removed. Sometimes the ovary on the same side is damaged and must also be taken out. The nursing care following operation is the same as for other laparotomies. SUMMARY The repair of congenital deformities of the female generative tract and the repair of injuries to it resulting from childbirth Constitute a large part of gynecology. The rupture of an extra- uterine pregnancy is serious and requires emergency operation. NEOPLASTIC DISEASE OF FEMALE GENITAL TRACT 6.13 VOCABULARY REVIEW hematocolpos cystocele ectopic pregnancy sterility rectocele pessary tubal insufflation colporrhaphy prolapse vesicovaginal ſistula SUGGESTED READING 1. Brady, Leo, Kurtz, Ethna L., and McLaughlin, Eileen: Essentials of Gynecol ogy. 2nd Ed. New York, The Macmillan Co., 1950. . Pisani, Bernard J.: Management of Ectopic Pregnancy with Massive Intra peritoneal Hemorrhage and Shock. Surg., Gynec. & Obst., 95:149-154 (Aug.) 1952. 3. Longley, Jay R., and Greene, Laurence F.: Urologic Procedures Employed in the Diagnosis of Urinary-Vaginal Fistulas. Surg., Gynec. & Obst., 94:709– 711 (June) 1952. 4. Miller, Norman, and Hyde, Betty: Gynecology and Gynecological Nursing. 2nd Ed. Philadelphia, W. B. Saunders Co., 1949. Wharton, L. R.: Treatment of Certain Congenital Malformations of the Female Genito-Urinary Organs; Resume of Recent Progress. Obst. & Gynec. Surv., 2:365-374 (June) 1947. 2 5 CHAPTER 51 Neoplastic Disease of the Female Genital Tract BENIGN TUMC)RS OF THE VULVA The commonest benign tumors of the vulva are fibromas (Con- nective tissue tumors) and lipomas (fatty tumors). They are treated by excision, which is a simple procedure. Leukoplakia; Kraurosis Vulvae. Leukoplakia is a disease of the vulva in which the skin becomes thickened and white. Kraurosis vulvae is a shrinking of the subcutaneous tissues which fre- quently accompanies leukoplakia. Leukoplakia is usually seen in women past the menopause, but sometimes occurs in younger women and is important because it frequently progresses into cancer of the vulva. In leukoplakia the whole vulva may appear shrunken and distorted; the skin is white and Shiny and may show cracks. The symptoms are intense itching and burning of the vulva, which are a heavy tax on the nervous system. 614 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS Treatment. Mild cases are treated conservatively with SOOth- ing ointments, thyroid, estrogenic hormone, vitamin A, x-ray therapy, or subcutaneous injection of the vulva with alcohol. Severe cases are treated surgically by excision of the vulva. CARCINOMA OF THE VULVA Cancer of the vulva is a relatively common disease which, in most cases, arises from the squamous epithelium with which the vulva is covered. It is primarily a disease of older women; in about 50 per cent of patients it is preceded by leukoplakia of the vulva. The disease appears first as an ulcer on the vulva which increases in size and assumes a cauliflower-like appearance. It metastasizes early to the inguinal lymph glands. The symptoms are itching and burning of the vulva, although the disease may be asymptomatic in the early stages. Treatment. If the disease is not too extensive, the treatment is excision of the vulva combined with excision of the inguinal and ſemoral lymph glands on both sides. This is often followed by deep x-ray therapy. If the disease is too extensive for operation, it is treated with deep x-ray therapy, which may sometimes be combined with radium therapy. Vulvectomy General anesthesia is used. Vulvectomy is best done with the electrosurgical cautery since the vulva is highly vascular and bleeds profusely. A circular incision is made at the vaginal orifice and another at the lateral borders of the vulva and the whole vulva is excised. The excision of the inguinal lymph glands is sometimes done at the time of the vulvectomy, and sometimes two weeks later. In this operation an incision is made over the inguinal ligament on each side and the superficial inguinal lymph glands are excised. Then the inguinal ligaments are di- vided and the deep lymph glands resected. Nursing Care. The patient usually returns from the operating room with sterile dressings over the vulva as well as over the inguinal regions, and with a retention catheter in the bladder. The catheter should be immediately connected to the straight drainage tubing, and the urinary output charted at regular intervals. The patient is kept ſlat in bed to prevent pressure on the suture line. When the dressings become soiled, usually on the second or third day, they are removed and a cradle is placed NEOPLASTIC DISEASE OF FEMALE GENITAL TRACT 615 over the patient. If a light cradle is used, the temperature is kept low to prevent burns. Warm perineal irrigations, usually of I to 8000 potassium permanganate, are started when the dressings are removed and are given three times daily and as required. About the tenth postoperative day the retention catheter is re- moved. Some separation of the posterior part of the incision usually takes place but is followed by healing. On the tenth post- operative day the patient is usually gotten out of bed; sitz baths are begun at this time. BENIGN TUMCRS OF THE CERVIX The only common benign tumor of the cervix is the cervical polyp. This tumor appears as a bright red, round, Oval or elon- gated body which presents at or protrudes from the external os. It usually arises from the lining of the cervical canal rather than the vaginal surface of the cervix. Most cervical polyps are benign, although cancer arises in a polyp occasionally, and early cancer may have a polypoid appearance. The symptoms of cervical polyp are intermenstrual bleeding, which is usually not profuse but is recurrent, and leukorrhea. The latter is due to in- ſection in the cervix or in the polyp. All cervical polyps should be removed and examined under the microscope to rule out evidence of cancer. Unless the polyp has a broad pedicle or the patient is very nervous, the polyp may be removed in the dispensary or office by clamping it and twisting it off. MYOMATA UTERI These tumors, which arise almost exclusively in the body of the uterus, are fibromyomata, that is to say, composed of both smooth muscle and connective tissue. They are usually spoken of as fibroids, and are by far the commonest tumor of the uterus. Their cause is unknown, although there is evidence to indicate that the estrogenic hormone may be a factor in their formation. Although most myomas are relatively small when encountered, they may attain enormous size. In Cullen's famous case the tumor itself weighed 86 pounds and the patient weighed only 84 pounds after the operation. Myomas are usually spheroid or oval in shape and tend to be multiple. Some are pedunculated and are con- nected to the uterine wall by a thin pedicle which contains their blood supply. Pedunculated tumors may become attached to an 616 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS Podunculoted aubserous myome Interstitial my &/3ozza” FIGURE 166. Myoma of the uterus. adjacent organ such as the omentum or intestine from which they receive part of their blood supply. Such myomas are said to be parasitic. Because of insufficient blood supply myomas sometimes become necrotic or cystic. Calcification may occur. Malignant degeneration is discussed in the section on sarcoma of the uterus (p. 623). A closely allied tumor, the adenomyoma, is discussed in the section on endometriosis. Myomas are frequently asymptomatic, particularly iſ small. The most important symptom is vaginal bleeding which usually takes the form of prolonged, proſuse menstrual ſlow. The bleed- ing may be so profuse as to produce a serious anemia. It is un- usual for bleeding from myomas to occur after the menopause, when these tumors usually regress. Another group of symptoms such as a bearing-down sensation in the pelvis and frequency of urination are the result of the pressure of the tumor on the sur- rounding organs. Pressure on the rectum may cause Constipation. Fibroid tumors are frequently the cause of sterility and often cause abortion. Iſ large tumors are located in the lower part of the uterus, they may interſere with the birth of the child if preg. nancy does occur. Diagnosis is usually not difficult. An enlarged, hard, multinodular uterus is pathognomonic of myomata uteri. Occasionally fibroids cause a soft, symmetrical enlargement of the uterus that is difficult to differentiate ſrom pregnancy. In this case a pregnancy test usually settles the diagnosis. Small sub- mucous fibroids frequently bleed profusely but cannot be felt on NEOPLASTIC DISEASE OF FEMALE GENITAL TRACT 617 Utzrus FIGURE 167. Total hysterectomy. The left ovary and tube will not be removed; the stumps of the uterine ligaments and the edges of the perito- neum will be sutured over the suture line which closed the opening in the upper vagina. pelvic examination. Such tumors can, however, be felt with the curette when the uterine cavity is curetted. Treatment. The treatment of myomata uteri depends largely upon the age of the patient and the symptoms. Small asympto- matic tumors require no treatment, but the patient should be examined at regular intervals to determine the rate of growth of the tumor. Fibroids usually stop growing and may even de- Crease in size after the menopause. Tumors which are sympto- matic are usually removed together with the uterus (hystero- myomectomy). Removal of the myoma alone (myomectomy) is Sometimes done in patients having only a few tumors who wish to have children. Women near the menopause who have small Symptomatic fibroids are sometimes treated with radiation rather than operation, particularly if they are poor operative risks. This treatment is given only after a dilation and curettage has 618 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS been done to rule out malignant disease. Either deep x-ray ther- apy or intra-uterine radium therapy is given. With either type of therapy an artificial menopause is brought about. CARCINOMA OF THE CERVIX With the exception of cancer of the breast, cancer of the cervix is the commonest malignant tumor in women. Although carcinoma of the cervix is usually thought of as a disease of older women, this is not strictly true. It is not uncommon in women below the age of 35, but the majority of cases occur be- tween the ages of 35 and 50 years. Most gynecologists believe that childbirth injuries to the cervix are a predisposing factor. In 95 per cent of the cases, cancer of the cervix arises from the squamous epithelium covering the cervix. Five per cent are adenocarcinomas which arise from the cervical glands. Carcinoma of the cervix may begin either on the surface or within the cervical canal. Later, either a progressive ulcer or a protruding, fungating tumor appears. In this later stage secondary infection of the tumor with pyogenic bacteria usually occurs and produces a ſoul-smelling discharge. The disease spreads to the vaginal mucous membrane or to one or both broad ligaments by way of the lymphatics. Later, the tumor may metastasize to the adjacent lymph nodes, or to the vulva, bladder, or rectum. Cases are clas- sified by a standard clinical nomenclature according to the extent of the disease: stage zero, the earliest stage, is that in which the cancer is limited to the cervical epithelium; stage one is that in which the disease is confined to the cervix; stages two, three and four represent progressively more extensive lesions. Symptoms. The commonest symptom of cancer of the Cervix is intermenstrual or postmenopausal bleeding, or leukorrhea, which in the later stages is profuse and foul-smelling. In the early stages bleeding is usually slight, but later extensive hemorrhages may occur. Intermenstrual or postmenopausal bleeding is a danger signal which should always be investigated immediately. In 50 per cent of the cases, postmenopausal bleeding is caused by malig- nant disease. The diagnosis of cancer of the cervix must always be confirmed by biopsy before treatment is begun. Abnormal bleeding is always an indication for curettage of the uterine cavity and cervical canal, for a hidden cancer may be present even though the cervix appears normal. Treatment. The standard treatment of cancer of the cervix is NEOPLASTIC DISEASE OF FEMALE GENITAL TRACT 619 irradiation. For suitable, carefully selected patients, however, a radical operation (panhysterectomy) achieves good results. At- tempts are being made, in addition, to find out if patients with late, widespread disease can be helped by very radical surgical procedures such as pelvic exenteration. In these extensive opera- tions, the entire contents of the pelvis, including the genital organs, bladder, and rectum are removed; the patient is given a permanent colostomy, which is also the route of urinary excre- tion because the ureters must be transplanted from the bladder into the colon. Radiation therapy, as used in most clinics, Consists of a Com- bination of deep x-ray and radium therapy. The average per- centage of the five-year survivals of all patients treated with radiation therapy is 35 per cent. The majority of patients do not seek treatment until the disease is already far advanced (stages three and four); the percentage of cures would be much higher if treatment could be begun in the earlier stages. There- fore, an extensive campaign has been conducted designed to educate the public, so that people with cancer will seek treat- ment while the disease is still in an early stage. Radical Panhysterectomy for Carcinoma. General anesthesia is used. This operation is performed through a low midline in- cision. It differs from the usual conservative panhysterectomy in that as much as possible of the para-uterine tissues, including the pelvic lymph nodes, is removed, together with the entire uterus and both tubes and ovaries. The pelvis is sometimes drained with a vaginal cigarette drain at the end of the operation. NURSING CARE FOLLOWING RADICAL PANHYSTERECTOMY. Psycho- logic and emotional factors are important in the care of the pa- tient anticipating hysterectomy. Before admission to the hospital the patient has had an explanation Concerning the operation, but many women hesitate to ask the male physician intimate questions. The nurse should try to establish rapport by taking an active interest in the patient to encourage the latter to voice her apprehensions. It is to be expected that a young woman who has not borne children may be very depressed. The mother who al- ready has her family is less concerned about the loss of the uterus and its functions. However, many women have heard tales about the effects of hysterectomy which are likely to cause anxiety unless corrected. Some of the ideas which are common include gaining weight, loss of libido and inability to be a satisfactory 620 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS mate. Sometimes the patient even has difficulty in accepting the fact that she may never menstruate again. Another reason for emotional distress is the fear of persistent cancer. The manner oſ preparing ſor hysterectomy is the same as that ſor laparotomy. Postoperatively, the care is also similar to that given to patients with abdominal surgery. Special nursing care is directed toward the prevention of urinary retention. Fre- quently, there is unavoidable trauma to the bladder which re- sults in loss of muscle tone. Some surgeons instill 1 ounce of 0.5 per cent aqueous mercurochrome into the bladder following the operation. This causes slight irritation to the mucosa, stimu- lating a desire to void beſore the bladder becomes distended with urine. The methods previously described should be used to initiate voiding. It is important that these be started soon after opera- tion for when the bladder is permitted to become distended, the patient becomes increasingly uncomfortable and less able to void. If the patient cannot void, then she must be catheterized. Whenever the patient complains of discomfort, her complaint should be respected and she should be catheterized until she is able to void voluntarily. If the patient voids less than 100 cc. at a time during the first eight hours after operation, she should be catheterized; this should be repeated until she can void larger amounts. Voidings of 100 cc. or more of urine usually signify that the patient has control of bladder function. This is a fairly safe rule but is not always correct. The nurse should examine the pa- tient's abdomen and heed her complaints for, at times, there may be quite a large amount of urine in the bladder. The nurse should make frequent observations when intravenous fluids are given, especially when glucose is given because of its stimulating action upon the kidneys. Following operation, the preclimacteric patient who has under- gone removal of both ovaries will experience “hot flashes.” These may occur as early as the fourth or fifth postoperative day. The symptoms of surgical menopause vary but are often more severe than those accompanying normal menopause. “Flashes of heat” are sometimes frequent and hot flushes are troublesome because of sweating which may occur at the time. Other symptoms most commonly manifested are palpitation of the heart, irritability, and ſrequent attacks of wakefulness. The doctor may order the administration of estrogenic substances which lessens the symp- toms. These are not ordered when the patient has cancer because NEOPLASTIC DISEASE OF FEMALE GENITAL TRACT 62] ºrº. * ºx. w %iº §º §§§ § SS FIGURE 168. Carcinoma of the cervix of the uterus being treated with radium. One radium tube is in the cervical canal, and a pack of tubes, as shown in the insert, is fastened against the surface of the cervix. The bladder is kept empty to prevent a burn, and the gauze pack- ing in the vagina serves to hold back the bladder, vaginal walls, and rectum as much as possible, also to prevent radium burns. of danger of making the malignancies grow more rapidly. Some doctors prescribe mild sedatives which permit adequate rest and also tend to reduce the symptoms. Some surgeons implant pel- lets of estrogenic substances into the rectus muscles to control the menopausal syndrome. These may last up to fifteen months, pre- venting the necessity for intramuscular injection or oral ad- ministration of estrogens. In all cases, the nurse must stress follow-up care. The time for checkup varies with surgeons; the patient should understand when she is to return to her doctor. Radiation Therapy. In treating carcinoma of the cervix, one or more radium treatments may be given. The radium is usually inserted with the patient under general anesthesia. After dilation of the cervix, a rubber or metal tube containing the radium capsules is inserted into the cervical canal. It is usually fastened in place with a linen or silk suture. If radium is to be applied to the surface of the cervix at the same time, a metal or cloth plaque containing the capsule is placed against the surface of the cervix and is held in place with a gauze vaginal pack. The whole vagina is then packed to prevent the radium from burning the vaginal wall. Lastly, a mushroom catheter is placed in the bladder to keep it collapsed and out of the way of the radium. The patient is then returned to the ward until it is time to remove the 622 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS radium, when she is taken back to the operating room. The duration of radiation depends on the quantity of radium applied and the total dosage desired. When the patient returns from the operating room with the radium in place, the retention catheter is connected with the straight drainage tube and the urinary output is measured every three or four hours. Should the catheter fail to drain, the doctor must be notified at once since a full bladder may lead to a radium burn. The patient is kept as quiet as possible in bed to prevent the radium from becoming dislodged. Since radium is expensive, bedpans and bed linen must be carefully examined for radium containers or gauze packs when they are removed. Should a radium applicator be discovered, it should never be touched with the fingers, but always handled with a long instrument. Its dis- covery must be reported at once. It is advisable for these patients to be kept as far as possible from other patients while the radium is in place. Profuse vaginal bleeding or high fever may occur during treatment and should be reported. Antibiotic therapy is administered routinely while the radium is in place. Sedation is given as needed. Otherwise these patients receive routine care. CARCINOMA OF THE BODY OF THE UTERUS In contradistinction to cancer of the cervix, most cases of Can- cer of the body of the uterus occur after the menopause. A few cases occur at an earlier age, the youngest in the Johns Hopkins series being 28 years old. The ratio of frequency of carcinoma of the body of the uterus to carcinoma of the cervix is one to eight. Cancer of the body of the uterus is an adenocarcinoma which arises from the endometrial glands. As the tumor grows, it spreads over the endometrium and invades the uterus which, in time, it may perforate. As the tumor increases in size, the body of the uterus enlarges. The tumor sometimes spreads to the fal- lopian tubes, or to the surfaces of the ovaries, or to the nearby peritoneum. Metastases to the lymph nodes around the bifurca- tion of the aorta occur late. Metastases to distant organs are found at autopsy in one third of the cases. Symptoms and Diagnosis. The Cardinal symptom of carcinoma of the body of the uterus is abnormal vaginal bleeding. Since most cases occur after the menopause, every case of postmeno- pausal bleeding must be presumed to be due to carcinoma until proved otherwise. On examination the uterus may feel perfectly normal in early cancer, whereas in more advanced cases the NEOPLASTIC DISEASE OF FEMALE GENITAL TRACT 623 uterus may be enlarged or irregular. In any case, diagnosis must be confirmed by microscopic examination of the uterine Curet- tings. Treatment. Experience has shown that the best treatment for cancer of the body of the uterus is a combination of radiation and panhysterectomy with removal of both fallopian tubes and ovaries. In treating such a patient, it is customary first to give either intrauterine radium therapy or a course of deep x-ray ther- apy, and to operate four to six weeks after completion of the radiation. The technic of applying radium to the uterine cavity is somewhat similar to that for treating the cervix. A different applicator is used and the radium is applied to the whole length of the uterine cavity. The nursing care is the same. PostOpera- tive care following panhysterectomy is the same as after other laparotomies. The vaginal cigarette drain if used is removed on the third or fourth postoperative day. SARCOMA OF THE UTERUS This is a rare malignant tumor arising in the uterine muscle. Most sarcomas arise in benign myomas and the remainder di- rectly from the uterine muscle. A hard, nodular uterine tumor which bleeds or grows rapidly after the menopause is always suggestive of sarcoma, and should be immediately removed by panhysterectomy. If the pathologic studies of a supposed benign tumor reveal sarcoma, deep x-ray therapy is usually given after operation. The nursing care is the same as for any laparotomy. OVARIAN CYSTS Graafian Follicle Cysts. There are many different types of ovarian cysts. The simplest is the graafian follicle cyst, which arises from a follicle which has ſailed to rupture but, instead, has degenerated and become enlarged. The fluid which fills such a cyst is secreted by the granulosa cells lining it, and is rich in the estrogenic hormone. Sometimes there are many such cysts, caus- ing the ovary to be somewhat enlarged. Such cystic ovaries are often associated with endometrial hyperplasia and with func- tional uterine bleeding. Corpus luteum Cysts, and Hematomas. Another type of cyst which is associated with the graafian follicle is the corpus luteum cyst. The corpus luteum is always cystic, but sometimes the cavity at the center is abnormally large, so that the ovary is increased in 624 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS size. Such a structure is known as a corpus luteum cyst if it is filled with clear fluid. If it is filled with blood, as sometimes occurs, it is spoken of as a corpus luteum hematoma. These are often associated with pain or with menstrual irregularities, and such cases may be difficult to differentiate from appendicitis or ectopic pregnancy. Serous Cysts. A type of larger ovarian cyst has a single cavity and is filled with clear fluid; this is the simple serous cyst. Cysfadenomas. These are a group of more Complicated tumors which at times attain large size. These may have one or more separate cavities; tumors with several cavities are spoken of as multilocular. Cystadenomas may have a smooth lining but some- times the lining is covered with many small projecting nodules; such tumors are spoken of as papillary. Iſ they contain a thin watery fluid, they are described as serous; if the fluid is gelatinous, they are called pseudomucinous cystadenomas. In the serous type in particular the papillary structures at times spread to the neighboring abdominal organs, and the abdomen may become filled with ſluid; these complications sometimes subside when the ovarian tumor is removed by the surgeon. Dermoid Cysts. These tumors contain many different tissues having separate origins, which eventuate in such varied struc- tures as hair, glands, teeth, and bone. Dermoids are really sepa- rate individuals growing inside the ovary, and are thought to arise early in embryonic life. Dermoid cysts seldom become larger than grapefruit, and are usually benign. Teratomas are related tumors which also contain many different tissues; however, these are always solid tumors, and are nearly always malignant. OVARIAN CARCINOMA Cancer of the ovary originates directly from the normal epi- thelial tissues of the ovary, or from a previously existing benign Ovarian tumor. It may also be a metastasis from a cancer of the gastrointestinal tract, in which case it is spoken of as a Kruken berg tumor. Secondary carcinoma of the ovary may also originate in the uterus or ſallopian tube. Fifteen per cent of all ovarian tumors are malignant. Grossly they are either solid or cystic; the Cystic tumors usually contain much papillary material. These tumors spread most commonly to the neighboring organs by way of the peritoneum, and large quantities of fluid may accumulate in the peritoneal cavity. In cases where the carcinoma is in- operable, the fluid may need to be drained off (paracentesis) at NEOPLASTIC DISEASE OF FEMALE GENITAL TRACT 625 frequent intervals. More than five barrels of fluid were removed from one such patient over a period of several years. Fibromas. A word may be said about ovarian tumors which arise from connective tissue. These are called fibromas. They are solid tumors which sometimes become fairly large, and are com- monly associated with ascites, and sometimes with hydrothorax. Malignant tumors of Connective tissue origin are rare. Granulosa Cell Tumor; Arrhenoblastoma. The granulosa Cell tumor is a feminizing, and arrhenoblastoma a masculinizing tumor. Both arise from primitive cells having in the first instance feminine, and in the second, masculine characteristics. The granulosa cell tumor secretes the estrogenic hormone, the ar- rhenoblastoma secretes the male sex hormone. If a granulosa cell tumor appears before puberty, early or precocious puberty re- sults. If it occurs after the menopause, regular menstruation sometimes reappears after many years of amenorrhea. Appear- ance of an arrhenoblastoma in a normal woman produces such changes as atrophy of the breasts, increase in body hair, change in the voice, cessation of the menses, and enlargement of the clitoris. In both types of tumors the symptoms disappear when the tumor is successfully removed. Trecitment of Ovcırican Tumors The treatment of ovarian tumors depends on the type of tumor. Graafian follicle and corpus luteum cysts usually require no treatment. The other neoplastic tumors of the ovary, iſ they have attained any size, must be removed surgically when the diagnosis is made. It is usually necessary to remove the fallopian tube to- gether with the ovary on the affected side. In cases of carcinoma of the ovary, both ovaries, and the uterus also if possible, are re- moved, regardless of whether metastases are present or not. Such patients should always be operated on, no matter how hopeless the situation may appear to be, since surgery presents the only hope of cure. Deep x-ray therapy is usually given after opera- tion, and is sometimes beneficial. ENDOMETRIOSIS One interesting cyst with which all nurses should be familiar is the endometrial cyst. Such cysts are filled with chocolate-colored fluid, and are often described as “chocolate cysts.” The fluid is really old blood, which owes its presence to the fact that the cyst walls contain endometrial tissue like that lining the uterine 626 NURSING IN SURGERY OF THE REPRODUCTIVE ORGANS cavity. Whenever the patient menstruates, bleeding takes place into the cyst, where the blood gradually accumulates. This condition is also known as endometriosis of the ovary. The Ovary, however, is not the only place where endometriosis occurs: it is also found in the uterine wall, which may be riddled with patches of endometriosis. In some cases, these form discrete tumor masses, appearing grossly much like simple myomas but showing typical endometrial tissue on microscopic examination. Other locations in which endometriosis is often found are the outer surface of the uterus, the fallopian tubes, rectovaginal septum, uterosacral ligaments, sigmoid colon, vagina, bladder, and umbilicus. There has been much speculation as to the origin of endometri- osis, and a number of theories have been advanced in an attempt to explain this disease. The theory of Sampson is ingenious, and probably accounts for some cases at least. Sampson believed that endometriosis is caused by menstruation backward through the fallopian tubes into the pelvis, and that bits of endometrium are carried along with the flow, finally becoming implanted on the pelvic organs. This theory is supported by the fact that retrograde menstruation has been observed in people with retrodisplace- ment of the uterus, and that endometriosis is commoner in such individuals. A second theory supposes that endometrium can be formed from another pelvic tissue called germinal epithelium by a process known as metaplasia. Bleeding into the pelvis occurs from all the areas of endo- metriosis as long as menstruation continues. The blood is irritat- ing to the peritoneal surfaces, and causes severe pain at the time of menstruation. It also causes dense adhesions to form between the pelvic organs. When endometriosis occurs in the umbilicus or bladder or in operative scars, as it sometimes does, the patient has external bleeding from these locations. The commonest symp- tom complex is progressively more severe dysmenorrhea associ- ated with memorrhagia (prolonged profuse menstrual periods). After a time the pain usually becomes so severe that the patient demands relief. The symptoms generally subside after an arti- ficial or surgical menopause has been brought about. Treatment. In young women with endometriosis the attempt is usually made first to control the patient's symptoms with seda- tives. Should operation become necessary, as it often does, the operator tries to save sufficient ovarian tissue so that the patient may have children. Such a patient is advised to have her family NEOPLASTIC DISEASE OF FEMALE GENITAL TRACT 627 as soon as possible, since sterility often results as the disease progresses. In addition to removal of as many of the endometrial implants as possible, both ovaries are removed from women near the menopause, for Castration stops the progress of the disease and often causes any remaining implants to atrophy. Patients who are poor operative risks are sometimes treated with radia- tion therapy, once the diagnosis has been established. This type of therapy has the same result as castration. SUMMARY Cancer of the female generative tract is the most common form of cancer in women; happily, it can be detected early and cured completely if women will have regular and adequate gynecologic examination. VOCABULARY REVIEW leukoplakia panhysterectomy exenteration vulvectomy cystadenoma curettage myoma endometriosis SUGGESTED READING 1. Cancer Nursing, A Manual for Public Health Nurses. Federal Security Agency and New York State Department of Health, 1950. 2. A Cancer Source Book for Nurses. American Cancer Society, Inc., New York, 1950. . Delaplaine, Robert W. et al.: Effective Control of the Surgical Menopause by Estradiol Pellet Implantation at the Time of Surgery. Surg., Gynec. & Obst., 94:323–333 (March) 1952. 4. Duker, Teresa: Nursing Care in X-ray Therapy of Cancer and Allied Dis- eases. Pub. Health Nursing, 44:680–683 (December) 1952. . McLaughlin, Eileen: Nursing Care in Hysterectomy. Am. J. Nursing, 50: 295–298 (May) 1950. 6. Nolan, James F., and DuSault, Lucille: The Elimination of Untoward Radiation Sequelae in the Treatment of Carcinoma of the Uterine Cervix. Surg., Gynec. & Obst., 94:539–542 (May) 1952. 7. Ranney, Brooks: Endometriosis. Am. J. Nursing, 52:1465–1466 (December) 1952. 8. TeLinde, Richard W.: Hysterectomy. Am. J. Nursing, 50:293–295 (May) 1950. 9. Tyronne, Curtis, and Weed, John C.: Hysterectomy. A Personal Experience with Two Thousand Consccutive Cases in Private Practice. Ann. Surg., 133: 819–829 (June) 1951. 10. Walker, Elizabeth: Cytologic Test for Cancer. Am. J. Nursing, 49:43–45 (January) 1949. 3 5 Unit XIII. COMMUNICABLE DISEASE CHAPTER 52 Communicable Diseases in Surgery Only a small portion of the large subject of communicable dis- ease is of surgical importance. Although any surgical patient may contract such communicable diseases as measles, mumps, and the like, the treatment of these diseases is medical. The fact that the initial phase of some of them may give rise to abdominal or other symptoms and signs which simulate surgical conditions, especially in children, has been mentioned (p. 247). In the course of certain of the communicable diseases, however, complications sometimes arise that require surgical treatment. Among these are intestinal perforation due to typhoid, contractures of ex- tremities resulting from poliomyelitis, empyema caused by pneu- monia, and pelvic abscess secondary to gonorrhea in the female. There are many more, and considerable discussion of them has already appeared in this text. Strictly speaking, the Ordinary surgical infections, such as those caused by the introduction of the common pyogenic bac- 629 630 COMMUNICABLE DISEASE teria into the tissues, are not communicable diseases in the sense that measles and chickenpox are; they may be and often are, however, spread from one patient to another, and this was the rule rather than the exception prior to the introduction and adoption of the principles of antisepsis and asepsis. It is always necessary to exercise extreme care when treating patients who have septic wounds in order to prevent the transfer of virulent bacteria to an uninfected patient. Many of the medical Com- municable diseases are transmitted by the bites of insects or larger animals, and some are spread by mechanical contact with excreta. This is also true of the surgical infections about to be discussed. RABIES (HYDROPHOBIA) This virus disease is fatal to man and animals. The virus is present in the saliva of the infected animal, and is thus trans- mitted by its bite. Rabies most commonly infects the dog, but it is also found, though rarely, in the cat, horse, cow, fox, wolf, and some others. The name hydrophobia is a misnomer; the rabid animal does not fear water but is unable to swallow because of spasm of the pharygneal muscles. The disease has a varying in- cubation period, usually forty to sixty days. Treatment. When treatment by the Pasteur method is given before the disease develops, rabies is averted; after the onset no form of treatment is successful. The Pasteur treatment consists in the inoculation of the patient with several increasing doses of material prepared from the spinal cord of infected animals. If a person is bitten by a dog, or any other animal, an immediate effort must be made to secure the animal. If it appears ill, examination of the brain must be made; if the animal remains perfectly healthy during an observation period of several weeks, there is no danger of rabies. If the animal cannot be located, however, or if it is found to be rabid, the Pasteur treatment must be given to the patient at once. TETANUS This disease, commonly known as lockjaw, is characterized by spasm (tetanic contraction) of the muscles of the body. Depend. ing upon the degree of intoxication, some or all of the muscles are affected, thus interfering with opening the mouth, swallow- ing, moving the extremities, or even breathing. In severe cases COMMUNICABLE DISEASES IN SURGERY 631 the patient dies as a result of respiratory paralysis, or of exhaus- tion from the prolonged muscular contraction. The tetanus bacillus produces this disease by manufacturing a powerful poison (tetanus toxin) that affects the nervous system. This microorganism is a strict anaerobe, and also has the ability to form spores; these are difficult to kill and under the proper condi- tions develop into the toxin-producing bacilli. Commonly found in the ſeces of animals, and occasionally in those of man, these spores are widely distributed, and are generally present in streets and fertilized fields. The usual manner of human infection is through a puncture wound, made perhaps by stepping on a nail or running a contaminated splinter through the skin. The bacilli do not stir up much inflammatory reaction in the tissues, and do not spread, remaining where inoculated; the toxin produced is then absorbed and carried throughout the body in the lymphatics and in the blood stream, and thus reaches the nervous system. As a minute amount of this toxin may cause death, the successful treatment of tetanus depends upon the neutralization of the toxin before a lethal amount reaches the central nervous system. Prevention. Since the disease has a high mortality rate, preven- tion is of the utmost importance. The accidental introduction of spores or bacilli is difficult to prevent, but fortunately two ade- quate methods exist for neutralization of tetanus toxin. The first of these is the administration of tetanus antitoxin, a serum pre- pared from animals (horse, cow, rabbit, pig) to which repeated Small sublethal doses of tetanus toxin have been given. These animals develop immunity, and by transfer of their serum to the patient, temporary immunity is considered. It is important to note that although antitoxin neutralizes toxin it does not destroy the bacilli; these, if permitted to do so, will continue to manu- facture toxin, so that the antitoxin will afford only temporary safety. Following the use of antitoxin minor degrees of serum sickness are common, including fever, urticara (hives), and pain- ful joints. More serious reactions are associated with edema and respiratory obstruction; these require prompt medical attention. A second and better method of preventing tetanus is by active immunization, which produces permanent immunity to the toxin. This immunization is accomplished by a course of toxoid inoculations, similar to the method employed in diphtheria im- munization. Active immunization is employed in the armed forces and has been spectacularly successful in preventing tetanus 632 COMMUNICABLE DISEASE among the wounded. Eventually, when all children receive tetanus toxoid, there will be little need for antitoxin, and tetanus will become rare. At present, however, in the case of every civilian having a wound in which the spores may be present tetanus antitoxin must be administered, unless he has previously been immunized, and in sufficient amount. The antitoxin, of course, is animal serum; patients must therefore be tested care- fully for sensitivity to avoid severe serum reactions. Treatment. Active treatment is necessary when tetanus has al- ready developed. The patients should receive large doses of anti- toxin by several routes: locally about the wound, intravenously, and also by injection into the spinal cord, so as to neutralize quickly as much as possible of the already existing toxin. The wound should be excised en bloc in order to remove the tetanus bacilli, thus preventing the manufacture of additional toxin. Nursing Care. As even slight stimulation excites a convulsion, absolute silence is advisable. Sedatives are needed to relax the muscle spasm; at times general anesthesia is necessary. Con- vulsions can be controlled to some degree by the use of barbitu- rates and Avertin. Narcotics, especially morphine, tend to depress the respirations so that they are rarely used. Patients in respira- tory distress are given oxygen; all patients need special attention to nutrition and fluids. When the jaws are not completely locked, fluids may be given by mouth. A rubber tip should be placed at the end of the drinking tube or Asepto syringe so that biting of the glass is prevented if the patient has a muscle spasm during the feeding. When the jaws are locked or when the patient is reluctant to take fluids by mouth it is advisable to feed the pa- tient through a tube introduced into the stomach through the nose. High caloric feedings should be given frequently in small amounts (200 cc. or less). The advantages of this are that there is only slight disturbance of the patient and there is no danger of aspiration. The urinary output should be watched carefully. The patient is usually incontinent of urine so that frequent bathing with soap and water is essential to prevent bedsores. Recovery, when it occurs, is slow and gradual; by degrees the spasticity of the mus- cles disappears. * In patients who are very seriously ill, with spasms interfering with adequate respiration, it has been found possible to tide them over the critical period by achieving paralysis of the con- tracted muscles by the use of curare. A tracheotomy is performed COMMUNICABLE DISEASES IN SURGERY 633 so that a clear airway can be maintained, and the patient is placed in a respirator to accomplish aeration of the lungs." GAS BACILLUS INFECTION There is a group of spore-bearing pathogenic anaerobes which produce gas as well as toxins. Of these, the organism most Com- monly encountered is the Welch bacillus. Such putrefactive anaerobes thrive especially well in wounds where there is much crushed muscle or deficient circulation; here the bacteria grow fast and the infectious process spreads rapidly. The spores of this group are found in the feces of man and animals, and are widely distributed in nature. Infections are apt to occur in severe wounds as, for example, compound fractures of the leg which are contaminated by soil or by dirty underclothing. The clinical picture is marked by sudden acceleration of pulse and rise in temperature, and by the appearance of bubbles of gas in the tis- sues. These bubbles may be seen in x-ray films, or are discovered by the characteristic crepitus, a sign in which palpation of the tissues gives rise to a crackling sensation similar to that observed in feeling excelsior through tissue paper. Unless measures are taken to stop the spread of the infection, death will probably occur in a few hours. Treatment. Once the infection has become clinically recogniz- able, only amputation or the wide excision of the infected tissues saves life. Here, too, the most important measure is proper prophylaxis. The value of careful débridement in order to pre- vent such infections was established in World War I. Crushed or devascularized tissue must be removed. Huge doses of anti- biotic agents, especially penicillin, are administered immediately upon beginning the treatment of the type of wound in which a gas infection might develop, especially a Compound fracture. Antitoxic sera are also available and should be used, but their value is questionable. Nursing Care. Patients having infections due to spore-bearing bacilli must be strictly isolated. Spores are difficult to kill and may survive in dust for long periods of time, ready to become active as soon as introduced into favorable surroundings. In the ward every precaution must be taken to prevent the transfer of bacilli or spores to uninfected patients; if possible the infected patient should be in a private room. Gowns and rubber gloves should be worn by all in attendance; if practicable, these at- 1 For nursing care of the patient in a respirator see Brown, pages 150–155. to pag 634 COMMUNICABLE DISEASE tendants should be relieved from duties with other patients. Linen, dishes, and utensils must be sterilized, and dressings burned. The bag containing the soiled linen in the room should be placed in a clean bag before it is taken to the laundry to pre- vent the linen from acting as a source of contamination while it is being transported. The nurse assisting with the dressing should place the soiled dressings in a paper bag. This bag should be placed in a clean bag provided by a clean nurse outside of the door, and taken at once to the incinerator. When there is no autoclave available in the ward for the sterilization of gloves, it is convenient to use a pressure cooker such as is ordinarily used in the canning of foods. The patient should not be released from isolation until repeated cultures from his wounds are sterile; he should then be transferred to a new bed, and his old bed and room disinfected. It is only by the conscientious observance of such strict measures that the disastrous transfer of spores to other patients can be prevented. Aside from the isolation precau- tions, the nursing care is that of an acutely ill, toxic patient. SKIN DIPHTHERIA The occurrence of virulent Klebs-Loeffler bacillus, the causa- tive agent of diphtheria, has been commonly observed in the past by pediatricians in ulcers of the extremities of patients known to have had recent diphtheria or exposure to it. In World War II widespread outbreaks of this same lesion occurred in adults. It is likely that the organism is a secondary invader of an already existing break in the skin; in any event, large necrotic ulcers occur, usually on the lower leg, and from these the diphtheria bacillus may be cultured. These bacteria are toxin- producers, and paralyses of various nerves or cardiac damage sometimes results from absorption of their toxin. Another serious complication is that the patient with such a lesion may be the source of an epidemic of pharyngeal diphtheria. Treatment. Treatment consists in rigid isolation of the patient, the local and systemic injection of diphtheria antitoxin, and such surgery as may be needed to heal the ulcer. OTHER INFECTIONS Infections due to some of the higher bacteria, the fungi, yeasts, and molds, are of surgical significance, though fortunately of rare occurrence. This group includes Actinomyces, Sporothrix, Blastomyces, and Coccidioides. These infectious agents produce COMMUNICABLE DISEASES IN SURGERY 635 granulomatous or ulcerative lesions which, if untreated, usually progress gradually to a fatal ending. It is fortunate that anti- biotic and chemotherapeutic agents are now available which can favorably influence some of these infections. Surgical interven- tion is indicated when abscesses form, or when necrotic tissue needs removal. SUMMARY Certain of the communicable diseases are of surgical sig- nificance. The surgeon who treats a dog bite must advise the Pasteur treatment to prevent rabies if the animal was or might be rabid. Every wound in which anaerobes might grow could result in tetanus; it is to be hoped that the entire population will be protected against this eventuality. VOCABULARY REVIEW rabies antitoxin blastomycosis tetan uS tularemia toxoid spore actinomycosis SUGGESTED READING 1. Christopher, Frederick: A Textbook of Surgery. 5th Ed. Philadelphia, W. B. Saunders Co., 1949, p. 86. 2. Firor, Warfield M.: The Treatment and Prevention of Tetanus. Am. J. Surg., 46:450–453 (Dec) 1939. 3. Shaughnessy, H. J., and Zichis, J.: Prevention of Experimental Rabies. J.A.M.A., 123:528–533 (Oct. 30) 1943. 4. Top, Franklin H.; Newer Drugs in the Treatment of Communicable Dis- ease. Am. J. Nursing, 49:700–704 (Nov.) 1949. ABDOMEN, anatomy of wall of, 224 anomalies of, 227 contents, 226 incisions, 230 subcutaneous injuries to, 288 Abdominal diagnosis, 228 distention, 93 Abdominoperineal resection of rec- tum, 328 nursing care, 328 Abortion, infected, 597 Abrasions, 6 Abscess, alveolar, 204 amebic, 276 appendical, 296 brain, 435 breast, 381 Cold, 549 ischiorectal, 322 liver, 275 lung, 112 nursing care of, 113 pelvic, 593, 595 peritonsillar, 496 renal, 345 subphrenic, 297 tubo-ovarian, 593 Achalasia of esophagus, 221 Actinomycosis, 634 Adamantinoma, 208 Addison's disease, 409 Adenofibroma, breast, 383 Adenoidectomy, 493, 494 Adenoids, irradiation of, 493 Adenoma of colon, 306 of thyroid, 400 Adrenal, neoplastic 408 Aerotitis, 505 Air embolism, 53 Airway, 88 disease of, INDEX Allergen, 391 Allergy, 391 Alveolar air, 102 Ambulation, 96 Amebic abscess, 276 Ampulla of Vater, 273, 279, 285 Amputation, 170 nursing care after, 171 Amylase test, 284 Anaerobic bacteria, 7, 14 infection, 172 Anaerobiosis, 26 Analysis, gastric, 253 Anaphylaxis, 391 Anastomosis, intestinal, 289 Anesthesia, positive pressure, 108 preparation for, 71, 76 Aneurysm, 160 intracranial, 436 Angina, Ludwig's, 204 Vincent’s, 204 Angiocardiogram, 183 Ankylosis, 513, 547 Anteflexion of uterus, 610 Antibiotics, administration of, 34 toxicity of, 34 Anticoagulant therapy, 155 Antisepsis, 2 Antithyroid drugs, 399 Antitoxin, 14 tetanus, 631 Anus, 319 Aphasia, 435 Appendectomy, 295 Appendicitis, 295 nursing care, 297 Arteriograms, 159 Arteriography, cerebral, 428 nursing care, 430 Arteriosclerosis, 165 Arteriovenous fistula, 162 637 638 INDEX Arthritis, 546 Ascites, 183 Asepsis, 2 Aseptic technic, 2 Astigmatism, 454 A telectasis, 92, 103, 104 Atomic energy burns, 375 Atrophy, optic, 464 Atropine, 76 poisoning, 454 Autograft, 357 Audiometer test, 481 Aureomycin. See Antibiotics. Automatic bladder, 340 Avulsion, 7, 13 BACITRACIN. See Antibiotics. Backache, 516 Balanitis, 564, 569 Balkan frame, 540 Basal metabolism test, 394 Bed, orthopedic, 540 postoperative, 90 Bedside notes, 86 Bedsores, 97 Benign tumors, 37 Benzidine test, 254 Bile, 272 pigment, 274 Biliany tract, cancer of, 279 surgery, nursing care, 283 Bilirubin, 274 Biopsy, 42 Bites, treatment of, 19 Bladder, carcinoma of, 342 incontinence, 341 irrigation, 341 stone, 346 Blastomycosis, 634 Blister, 9 Blood bank, 62, 66 crossmatching, 63 in urine, 344 pressure, measurement of, 89 Rh factor, 63 types, 63 Blue baby, 179 nursing care of, 189 Blue dome cyst, 382 B.M.R., 394 Bone, congenital deformities, 514 cysts, 552 fractures of, 527 growth and repair, 510 infection of, 547 neoplastic disease of, 550 tuberculosis of, 549 Bradford frame, 540 Brain abscess, 435 injury, 414 nursing care, 420 treatment of, 418 neoplastic disease of, 422 physiology of, 411 tuberculoma, 435 Breast, abscess, 381 adenofibroma, 383 carcinoma of, 384 hormone therapy, 386 nursing care, 387 radiation therapy, 386 cyst, 382 diseases of, 380 fat necrosis of, 381 lactation, 379 neoplastic disease of, 383 physiology of, 378 self-examination, 385 supernumerary, 378 virginal hypertrophy of, 365 Breathing tube, 88 Bronchial fistula, 104, 122, 126 Bronchiectasis, 116 treatment, 117 Bronchoscopy, 114, 116, 144 nursing care, I 15 Bruise, 9 Bruit, 158 Buerger's disease, 167 Bunion, 520 Burns, 369 atomic energy, 375 closed treatment, 370 contractures, 375 degree of, 369 diet in, 374 healing of, 373 lye, 214 nursing care, 376 open treatment, 371 shock in, 371 [NDEX 639 Burns, treatment teams, 372 Bursa, 512 Bursitis, 546 CAISSON disease, 154 Calculus, renal, 346 ureteral, 346 urinary bladder, 346 Caloric test, 481 Cancer. See Carcinoma and Neoplas- tic disease. Cantor tube, 243 Carcinoma, 39. See Neoplastic dis- 60S6. danger signals of, 43 follow-up care, 46 nursing care, 42 of biliary tract, 279 of bladder, 342 of breast, 384 of colon, 307 of ear, 504 of esophagus, 221 of kidney, 348 of lip, 207 of lung, 144 of ovary, 624 of pancreas, 285 of prostate, 577 of rectum, 327 of stomach, 259 of thyroid gland, 400 of tongue, 207 of uterus, body, 622 Cervix, 6.18 of vulva, 614 treatment of, 41 Cardiac massage, 178 standstill, 178 surgery, 178 nursing care, 183 tamponade, 178 Cardiospasm, 221 Carpal spasm, 404 Cartilage, 510 Castration, 563 in prostatic carcinoma, 578 Casts, nursing care of patients in, 536 removal of, 541 Cataract, 466 extraction, 467 nursing care, 468 Catheter, Foley, 576 Catheterization, cardiac, 183 female, 589 male, 566, 567 urinary tract, 340 Cauterization of cervix, 594 Cecostomy, 309 Cerebral Cortex, 412 Cerebrospinal fluid, 411 Cerumen, 504 Cervicitis, 596 Cervix uteri, carcinoma of, 618 Chalazion, 459 Chemical imbalance, 48 Chemosis, 476 Chemotherapy, 33 Chest, injuries to, 106 Chloramphenicol. See Antibiotics. Choked disk, 416, 464 Cholangiography, 283 Cholecystectomy, 281 Cholecystgastrostomy, 283 Cholecystitis, 276 Cholecystography, 280 Cholecystotomy, 282 Choledochojejunostomy, 283 Choledocholithotomy, 283 Cholelithiasis, 278 Cholesterin, 278 Chondrodystrophia fetalis, 514 Chordee, 565 Chordotomy, 445 nursing care, 446 Choroid (eye), 451 plexectomy, 424 Chvostek's sign, 404 Chyle, 153 Circumcision, 564 Claudication, intermittent, 166 Cleft lip and palate, nursing care, 201 palate, 200 Clubfoot, 518 Coagulation of blood, 58 Coarctation of aorta, 181 nursing care, 192 Cold packs, 31 Colectomy, 301, 310 640 INDEX Colic, gallstone, 277, 278 renal, 346 Colitis, chronic ulcerative, 300 Collapse therapy, 130 Colon, cancer of, 307 nursing care after surgery of, 311 preparation for surgery of, 307 resection, 310 Colostomy, 309 bag, 317, 344 nursing care, 312 Colporrhaphy, 609 Colpotomy, 595 Common duct, 273 Complications, postlaparotomy, 235 prevention of, 234 postoperative, 92 Compresses, cold, 31 eye, 473 hot, 30 Compression of chest, 107 Concussion of brain, 417 Congenital heart lesions, 179 Conjunctivitis, 460 Connell apparatus, 573 Consent to operation, 77 Constipation, 319 Continuous intravenous infusion, 55 Contractures, after burns, 375 Dupuytren's, 546 Contrecoup, 414 Contusion, 9 Convalescence, nursing care in, 95 Convalescent care, postlaparotomy, 237 Convulsions, 416, 419, 421 Cornea, ulcer of, 461 Cortisone, 392, 408, 457 Cosmetic surgery 364 Cranial nerves, 413, 438 Craniotomy, 431 nursing care, 433 Cretinism, 396 Crutches, 541 Cryptorchidism, 564 Cycloplegics, 454 Cystectomy, 342 nursing care, 343 Cysts of bone, 552 chocolate, 625 ovarian, 623 Cysts, pancreatic, 285 pilonidal, 357 Cystic duct, 277 Cystitis, 339 Cystocele, 608 Cystoscopy, air, 337 Care of instruments, 335, 338 nursing care after, 336 water, 334 Cystostomy, 340 Cystotomy, suprapubic, 57.1 DEAFNESS, 441, 507 Débridement, 14 Decompression of alimentary tract, 243 bladder, 57.1 apparatus for, 57.1 brain, 421 intestinal, 292 Decortication of lung, 109 Decubitus ulcer, 446 Dehiscence, 97, 236 Dermatome, 360 Desoxycorticosterone, 408 Detachment of retina, 458 nursing care, 459 Diabetes mellitus, 407 Diaphragm, hernia of, 109 Diathermy, 542 Dicumarol, 155 Diet, effect on bone, 510 after cleft lip and palate, 202 after gastrectomy, 267 after gastroenterostomy, 264 after gastrostomy, 216 after radical oral surgery, 210 after repair of tracheoesophageal fistula, 219 in burns, 374 in colon surgery, 308 low residue, 308 Meulengracht, 257 postlaparotomy, 237 postoperative, 95 Sippy, 257 Diphtheria, 634 Disaster teams, 372 Discission, 467 Dislocation, intervertebral disk, 444 traumatic, 525 INDEX 641 Distention, abdominal, 93, 237 Diverticula, esophageal, 219 Diverticulectomy, 299 Diverticulitis, 304 Diverticulum, Meckel’s, 298 Douche, 601 Drainage, bladder, Connell, 573 surgical, 14 water seal, 120 Dressing carriage, 17 Dressings, 16 abdominal, 233 Drops, technic of administration, 470 Drug (s) reactions, 33 sensitivity, 33, 392 used in ophthalmology, 474 Ductus arteriosus, 181 Duodenal fistula, 269 ulcer, 250 Dupuytren's contracture, 546 EAR, 503 Carcinoma of, 504 foreign body, 504 injury to, 504 wax in, 504 Early ambulation, 96 Ectopic kidney, 339 pregnancy, 611 Electrocoagulation, 59 Electroencephalography, 421, 429 Electrolytes, 48 Elephantiasis, 157 Embolectomy, 154 Embolism, 154, 533 air, 54, 154 fat, 154 Embolus, 154 Emphysema, subcutaneous, 108 Empyema of gallbladder, 277 thoracis, 103, 109, 122 nursing care, 125 treatment of, 124 tuberculous, 124 Encephalography, 428 Endocrine glands, 393 Endometriosis, 625 Enteritis, regional, 288 Entropion, 461 Enucleation of eye, 457 Epididymitis, 569 Epilepsy, 421 Epistaxis, 483 Epulis, 208 Erythema, postradiation, 45 Eschar, 375 Esophagogastrostomy, 222 Esophagoscopy, 215 Esophagus, achalasia, 221 cancer of, 221 diverticula of, 219 stricture of, 214 wound of, 213 Estrogen, 584, 620 Ethmoiditis, 486 Eunuchism, 563 Eustachian tube, 503 Evisceration, 97, 236 of eye, 458 Examination, pelvic, 587 Exenteration, pelvic, 619 Exophthalmos, 398 Exstrophy of bladder, 339 External auditory meatus, 503 Extradural hemorrhage, 417 Extrauterine pregnancy, 611 Eye, administration of drops, 470 compresses, 473 diseases of, 459 drugs used, 474 injury to, 455 irrigations, 472 neoplastic disease, 469 physiology, 449 FACE-LIFTING, 364 Fat embolism, 154 Fecal impaction, 320 Female genital organs, deformities of, 604 neoplastic disease of, 613 tuberculosis of, 599 Femoral hernia, 555 Fenestration operation, 508 Fibroids, 615 Fissure-in-ano, 321 Fistula, arteriovenous, 162 biliary, 284 bronchial, 104, 126 duodenal, 269 gastrocolic, 269 rectovaginal, 611 642 INDEX Fistula, tracheoesophageal, 217 vesicovaginal, 611 Fistula-in-ano, 323 Flatfoot, 519 Fluid balance, 48 Foley catheter, 576 Food poisoning, 300 Foreign body in ear, 504 in eye, 455 in nose, 484 wound healing, 12 Fowler's position, 241 Fractures, 527 complications, 532 compound, 531 nose, 484 ribs, 107 Frei test, 325, 601 Furuncle, 25 GALACTOCELE, 381, 382 Gallbladder, dye test, 280 empyema of, 277 physiology of, 273 removal of, 277, 278 Gallstone colic, 277, 278 Gallstones, 278 Ganglion, 553 Gangrene, 155 arteriosclerotic, 166 gas, 633 Gas bacillus, 633 gangrene, 633 Gastrectomy, 266 diet, 267 Gastric acidity test, 252 Cancer, 259 dilatation, 245 neoplastic disease, 259 Gastroenterostomy, 263 diet, 264 nursing care, 264 Gastroscope, 230 Gastroscopy, 254 nursing care, 255 Gastrostomy, 214, 262 nursing care, 216, 263 Gavage, 50 Genitalia, female, 580 deformities of, 604 Genitalia, female, infections, 592 neoplastic disease of, 613 tuberculosis of, 599 male, 56.1 infections of, 569 injuries to, 568 neoplastic disease, 570 Gibbus, 550 Glaucoma, 464 Glioma, 422 Glottis, 493 Goiter, colloid, 396 exophthalmic, 397 nodular, 397 Gonorrhea, 569, 592 arthritis, 547 tenosynovitis, 545 vulvovaginitis, 596 Grafts, 354 arterial, 161, 170 dermatome, 360 full-thickness, 359 pedicle, 360 skin, 357 small deep, 357 split-thickness, 359 tubed, 361 Granuloma inguinale, 600 Graves’ disease, 397 Gynecomastia, 380 HARELIP, 200 Hashimoto's struma, 400 Healing, 9 of burns, 373 of infections, 24 of wounds, 9 Hearing tests, 481 Heart, Catheterization of, 183 congenital defects, 179 Heat, application of, 28 dry, 28 moist, 29 Hematoma, 9 orbit, 456 subdural, 418, 436 Hematuria, 344, 348 Hemianopsia, 426 Hemoconcentration in burns, 372 Hemolytic jaundice, 195 INDEX 643 Hemophilia, 59 Hemoptysis, 143 Hemorrhage, 57 extradural, 417 internal, 61 nasal, 483 symptoms and signs of, 58 treatment of, 58 Hemorrhoidectomy, 322 Hemorrhoids, 321 Hemostasis, 3, 14, 58, 59 Hemothorax, 103 Heparin, 155 Hermaphrodism, 563 Hernia, abdominal, 554 congenital, 555 diaphragmatic, 109 femoral, 555 incarcerated, 555 incisional, 555 inguinal, 556 strangulated, 555 umbilical, 555 Herniated nucleus pulposus, 444 Herniorrhaphy, inguinal, 557 nursing care, 559 Hiccough, 235 Hip, congenital dislocation of, 517 Hirschsprung's disease, 306 Homans' sign, 165 Homograft, 357 Hormones, 393 female sex, 586 male sex, 562 Horseshoe kidney, 339 Hospital school, 522 Hyaluronidase, 52 Hydrocele, 565 Hydrocephalus, 423 Hydroma, subdural, 418 Hydronephrosis, 347 Hydrophobia, 630 Hydrotherapy, 542 Hydrothorax, 103 Hyoscine, 76 Hyperinsulinism, 408 Hypernephroma, 348 Hyperparathyroidism, 346, 404, 511, 552 Hypertension, 174 sympathectomy for, 174 Hyperthyroidism, 397 treatment of, 399 Hypodermoclysis, 51 Hypoglycemia, 407 Hypoparathyroidism, 404 after thyroidectomy, 402 Hypophysis, 406 Hypoproteinemia, 48 Hypospadias, 564 nursing care, 566 Hypothyroidism, 396 Hysterectomy, 617 ILEITIS, terminal, 288 Ileocolostomy, 310 Ileostomy, 289, 301 bag, 303 nursing care, 302 Ileum, perforation of, 288 tuberculosis of, 288 Ileus, mechanical, 290, 296 nursing care in, 293 paralytic, 242 Impaction, fecal, 320 Imperforate anus, 324 Incisions, 7 abdominal, 230 Incontinence, 446 paradoxical, 340 urinary, 341 Indigestion, 277 Induration, 24 Infection, 22 anaerobic, 633 female genital organs, 592 nursing care, 601 gas bacillus, nursing care, 633 nursing care of, 27 of mouth, 203 of wound, 27 postabortal, 597 puerperal, 597 Inflammation, 23 Infusion, intraperitoneal, 52 intravenous, 52 sets, preparation of, 54 subcutaneous, 51 Injury, thoracic, 106 nursing care, 110 to abdomen, 9, 288 to brain, 414 644 INDEX Injury to eye, 455 to heart, 178 to joints, 525 to kidney, 344 to muscle, 513 to musculoskeletal system, 524 to spine, 533 Intermittent claudication, 166 Intervertebral disk, rupture of, 444 Intestinal decompression, 292 intubation, 293, 308 obstruction, 242, 290, 296 resection, 289 Intracranial injury, treatment, 418 pressure, 415 Intravenous fluids, 52 Intubation, gastric, 261 gastrointestinal, 243 intestinal, 293, 308 Intussusception, 290, 305 Iodine deficiency, 397 in thyroid disease, 399 Iridencleisis, 465 Iris, 452 Irrigation, bladder, 341 colostomy, 315 empyema cavity, 125 eye, 472 tidal, 341 Ischemia, 155 Ischemic palsy, 532 Isolation technic, 35, 633 Isotopes, 42 radioiodine, 403 JAUNDICE, 274 hemolytic, 195 Jejunostomy, 289 Joints, 511 inflammation of, 546 injuries to, 525 tuberculosis of, 549 KELOIDS, 355 Keratitis, 462 Kidney, diseases of, 344 injury to, 344 neoplastic disease of, 348 Stone, 346 tuberculosis of, 345 Kyphosis, 515 LACERATIONS, 7 Lacteals, 153 Laminectomy, 445 nursing care, 446 Lamp, carbon filament, 28 infra-red, 28 Laparotomy, 224 Laryngectomy, 498 Laryngitis, 496 Laryngoscope, 481 Larynx, 492 infection of, 496 neoplastic disease of, 497 Legal consent to operation, 77 Leukoplakia of vulva, 613 Levin tube, 243 Lip, cancer of, 207 Liver abscess, 275 Lobectomy, 115 Logan bow, 202 Lordosis, 515 Loupe, 453 Ludwig's angina, 204 Lung, 101 abscess, 112 collapse, 103, 130 infection, 112 injuries, 106 neoplastic disease of, 143 physiology, 101 resection, 117, 145 tuberculosis, 130 Lymph, 150 Lymphadenitis, 25 Lymphangitis, 25 Lymphedema, 156 Lymphogranuloma venereum, 600 Lymphopathia venerea, 324 MALIGNANT tumors, 37 Mammaplasty, 365 nursing care, 366 Mammary gland, 378. See also Breast. Marginal ulcer, 269 Mastectomy, radical, 385 Mastitis, 381 chronic cystic, 382 INDEX 645 Mastoidectomy, 506 nursing care, 507 Mastoiditis, 505 Maxillo-facial surgery, 363 McBurney's point, 295 Mechanical ileus, 290 Meckel's diverticulum, 298 Mediastinum, neoplastic disease of, 147 Megacolon, 306 Ménière's disease, 441 nursing care, 441 Menstrual cycle, 584 Mesentery, 226 Metabolism, 48 Metastasis, 39 Meulengracht diet, 257 Miles operation, 328 Miller-Abbott tube, 243 Montgomery straps, 125 Morphine, 76 Mouth, surgery of, 200 Murmur, 158 Muscle, skeletal, 513 Musculoskeletal injuries, 524 nursing care, 535 neoplastic disease, 550 Myoma of uterus, 615 Myopia, 453 Myositis, 546 Myringotomy, 505 Myxedema, 396 NARCOTICS, use of, 90 Neoplasm, 36 Neoplastic disease, 36. See also Carci- 72O771.6l. adrenal, 408 bladder, 342 brain, 422 breast, 383 colon, 307 Csophagus, 221 eye, 469 female genital organs, 613 lung, 143 male genital organs, 570 mediastinum, 147 musculoskeletal, 550 nose, 492 oral cavity, 207 Neoplastic disease, paranasal sinuses, 492 pharynx and larynx, 497 prostate, 577 spinal cord, 445 stomach, 259 testis, 578 thyroid gland, 400 treatment of, 40 Nephrectomy, 348 Nephrolithiasis, 346 Nephrolithotomy, 346, 348 Nephrostomy, 348 Nerves, cranial, 413, 438 Neuralgia, glossopharyngeal, 440 sciatic, 444 trigeminal, 439 Neurologic bladder, 341 Nipple, discharge from, 384 diseases of, 380 Nonunion of fracture, 533 Nose, deviation of septum, 484 disturbances of, 483 foreign bodies, 484 fracture, 484 hemorrhage from, 483 neoplastic disease of, 492 submucous resection, 485 Nuclear fission burns, 375 Nucleus pulposus, herniated, 444 Nurse-patient relationship, 4 Nurse-surgeon relationship, 5 Nursing care, convalescent, 95 in abdominoperineal resection, 328 in amputation, 171 in appendicitis, 297 in arteriography, 430 in “blue baby” operation, 189 in brain injury, 420 in bronchoscopy, 115 in burns, 376 in carcinoma of breast, 387 in cardiac surgery, 183 in cataract, 468 in chordotomy, 446 in circulatory disease, 168 in cleft lip and palate, 201 in coarctation of aorta, 192 in colon surgery, 311 in colostomy, 312 l 646 solº Nursing care iſ craniotomy, 433 in cystectorhy, 343 in cystoscopy, 336 in dislocated disk, 444 in duodenal fistula, 269 in empyema thoracis, 125 in esophageal diverticula, 220 stricture, 215 in gallbladder surgery, 283 in gas bacillus infection, 633 in gastroenterostomy, 264 in gastroscopy, 255 in gastrostomy, 216, 263 in herniorrhaphy, 559 in hyperinsulinism, 408 in hypospadias, 566 in ileostomy, 302 in infection, 27 in laminectomy, 446 in laparotomy, 233 in lung abscess, 113 in mammaplasty, 366 in mastoidectomy, 507 in mechanical ileus, 293 in Ménière's disease, 441 in mitral stenosis, 192 in musculoskeletal injuries, 535 in ophthalmology, 469 in pancreatectomy, 285 in panhysterectomy, 619 in pelvic infections, 601 in plastic surgery, 366 in pneumonectomy, 146 in prostatectomy, 576 in pyloric stenosis, 250 in radiation therapy, 44 in radical oral surgery, 208 in rectal surgery, 325 in renal surgery, 349 in resection of esophagus, 222 in retinal detachment, 459 in segmental resection, 118 in sinusitis, 489 in splenectomy, 195 in submucous resection, 485 in sympathectomy, 174 in tetanus, 632 thoracic injury, 110 in thoracoplasty, 138 l thyroidectomy, 402 i I l i l Nursing care in tic douloureux, 440 in tonsillectomy, 495 in tracheoesophageal fistula, 218 in tracheotomy, 500 in traction apparatus, 535 in ulcerative colitis, 301 in ventriculography, 429 in vulvectomy, 614 in wounds, 21 of cancer patient, 42 of patients in casts, 536 postoperative, 81 preoperative, 70 Nutrition, 48 OBSTRUCTION, intestinal, 290 Oleothorax, 133 Operation, preparation for, 70 Ophthalmia neonatorum, 460 sympathetic, 457 Ophthalmoscope, 453 Oral cavity, surgery of, 200 Orchitis, 569 Orientation of patient, 98 Osteitis fibrosa cystica, 552 Osteochondrosis, 520 Osteomyelitis, acute, 547 chronic, 549 Otitis media, acute, 504 Otolaryngology, 478 Otosclerosis, 507 Otoscope, 480 Ovary, 583 carcinoma of, 624 cysts of, 623 Oxygen tent, 106 therapy, 105, 185 PAGET's disease of nipple, 380 Pain, relief of, 90 Palliation, 47 Palsy, crutch, 541 ischemic, 532 Pancreas, 407 adenoma of, 407 cancer of, 285 physiology of, 273 Pancreaticoduodenectomy, 285 Pancreatitis, 284 INDEX 647 Panhysterectomy, 619 nursing care, 619 Pannus, 461 Papilledema, 416, 464 Paradoxical incontinence, 340 respiration, 139 Paralysis, spastic, 522 of vocal cords, 402 Paralytic ileus, 242 Paraplegia, 443 Parathyroid adenoma, 404 glands, physiology, 403 Parenteral fluids, 50 Parotitis, 206 Pasteur treatment of rabies, 630 Patent ductus arteriosus, 181 Pelvic examination, 587 Penicillin. See Antibiotics. Peptic ulcer, 251 hemorrhage from, 258 perforation of, 252,258 Pericarditis, 179 Perimeter, 453 Perinephric abscess, 345 Perineum, 319 Periosteum, 510 Peritoneoscope, 230 Peritoneum, 225 Peritonitis, 239, 296 Pes planus, 519 Pessary, 610 Pharyngoscope, 481 Pharynx, 492 neoplastic disease of, 497 Phenolsulfonephthalein test, 334 Pheochromocytoma, 408 Phimosis, 564 Phlebitis, 164 Photophobia, 469 Phrenicectomy, 134 Physiology, gastric, 246 musculoskeletal, 508 of alimentary tract, 197 of biliary tract, 272 of brain, 411 of breast, 378 of eye, 449 of genital organs, female, 580 male, 56.1 of nose and sinuses, 481 of pancreas, 273 Physiology of parathyroid glands, 403 of pharynx and larynx, 492 of spinal cord, 411 of thyroid gland, 394 of urinary tract, 331 respiratory, 101 vascular, 149 Physiotherapy, 542 Pilonidal cyst, 357 Pituitary, 406 Plasma, 67, 372 expanders, 372 Plaster of paris, 536 Plastic surgery, 353 nursing care, 366 Pleura, 102 Pneumoencephalography, 428 Pneumonectomy, 115, 145 complications, 146 nursing care after, 146 Pneumonia, 93 Pneumonolysis, 134 Pneumoperitoneum, 133 Pneumothorax, 103 artificial, 132 tension, 104 Poliomyelitis, 521 Polycystic kidney, 339 Polydactylism, 363 Polymastia, 378 Polyp, rectal, 327 Polyposis of colon, 306 Portal circulation, 153 hypertension, 182 Positive pressure anesthesia, 103 Postabortal infection, 597 Postoperative care, 81 complications, 92 diet, 95 Postural drainage, 113 Pott's disease, 550 Pregnancy, ectopic, 611 extrauterine, 61 l tests for, 587 Premedication for anesthesia, 76 Preoperative preparation, 70 shaving, 71 Preparation for colon surgery, 307 of infusion sets, 54 of tubing, 54 Presbyopia, 454 648 INDEX Pressure, intracranial, 415 sores, prevention, 540 Proctology, 319 Proctoscopy, 320 Progesterone, 584 Propylthiouracil, 399 Prostate, benign hypertrophy of, 570 carcinoma of, 577 Prostatectomy, 57.1 nursing care, 576 perineal, 574 suprapubic, 572 transurethral resection, 575 Prostatitis, 570 Prosthesis, facial, 365 limb, 170 Pruritus, 275 anal, 321 Pseudohermaphrodism, 563 Psychosis, postoperative, 94 Puerperal infection, 597 Pulmonary embolism, 97, 154 Pulmonic stenosis, 179 Puncture wound, 7, 13 Purpura, 195 Pus, 24 Pyelitis, 344 Pyelography, intravenous, 336 retrograde, 336 Pyelophlebitis, 275, 296 Pyloric stenosis, 248 nursing care, 250 Pyloroplasty, 249 Pylorus, 247 Pyrogens, 54 QUECKENSTEDT test, 444 Quinsy, 496 RABIES, 630 Radiation sickness, 44 therapy, 42 of breast, 386 of carcinoma of cervix, 619, 621 nursing care, 44 Radioactive isotopes, 42 Radioiodine, 403 Radium therapy to adenoids, 493 Ranula, 208 Raynaud's disease, 167 Recovery room, 81 Rectal fissure, 321 fistula, 323 incontinence, 324 stricture, 324 surgery, nursing care, 325 Rectocele, 608 Rectum, 319 carcinoma of, 327 resection of, 328 Recurrent laryngeal nerve injury, 402 Refraction, 453 Refrigeration, 31, 170 technic of, 31 Regional enteritis, 288 Rehabilitation, 99, 543 of amputee, 172 Relaxed vaginal outlet, 608 Renal abscess, 345 9 colic, 346 excretion test, 334 shutdown, 57.1 surgery, nursing care, 349 Repair of wounds, 9 Reproductive organs, female, 580 male, 561 Resectoscope, 575 Respiration, maintenance of, 86 Respirator, 633 Respiratory tract, 101. See also Lung. Retention of urine, 340 Retina, 451 detachment of, 458 Retinitis, 464 Retroposition of uterus, 609 Rh factor in blood, 63 Rhinorrhea, 420 Ribs, fracture, 107 Riedel's struma, 400 Rubber tubing, preparation of, 54 Rubin's test, 606 Rutzen bag, 303 SALIVARY stones, 206 Salpingectomy, 596 Salpingitis, 593 Salpingo-oophorectomy, 596 Sarcoma, 39, 551. See also Neoplastic disease. uterus, 623 INDEX 649 Scalenus anticus syndrome, 168 Scar tissue, 12 Scars, plastic repair of, 355 Sciatica, 444 Sclera, 451 Scleroderma, 168 Scoliosis, 514 Scopolamine, 76 Segmental resection, 115, 117 complications, 121 nursing care after, 118 Self-examination of breast, 385 Semicircular canals, 504 Sensitivity, drug, 34, 392, 454 Sequestra, 549 Shaving, preoperative, 71 Shock, 67 due to burns, 371 treatment of, 68 Sigmoidoscope, 230, 320 Sims' position, 320 Sinus, pilonidal, 357 Sinuses, paranasal, 482 neoplastic disease of, 492 Sinusitis, 485 nursing care, 489 Sippy diet, 257 Sitz baths, 327 Skin grafts, 357 Slit lamp, 453 Snakebite, 19 Soaks, hot, 29 Speech training after cleft palate, 203 after radical oral surgery, 211 Spinal cord, 443 injuries, 443 neoplastic disease, 445 physiology of, 411 Spine, curvature of, 514 injuries to, 533 tuberculosis of, 550 Spirometer, 102 Splenectomy, 195 Splinting, 16 Sprains, 525 Standstill, cardiac, 178 Sterility, 605 Stomach, carcinoma of, 259 decompression of, 243 diets, 257, 267 Stomach, diseases of, 248 operations on, 261 nursing care, 264 physiology of, 246 ulcer, 251 Stomatitis, 204 Stone, renal, 346 ureteral, 346 urinary bladder, 346 Strabismus, 468 Streptodornase, 109 Streptokinase, 109, 126, 329 Streptomycin. See Antibiotics. Stricture, esophagus, 214 rectal, 324 Struma, 400 Stye, 459 Subcutaneous injury, 9, 288 Submucous resection, nursing care, 485 Subphrenic abscess, 297 Suction, waterseal apparatus, 118 Connell apparatus, 573 gastric, 243, 264 Sulfonamides, 33 Sump drain, 271 Surgery, cosmetic, 364 maxillo-facial, 363 Surgical drainage, technic of, 35 dressing carriage, 17 Suturing, 14 Sympathectomy, 173 Sympathetic ophthalmia, 457 Syncope, 67 Syndactylism, 363 Synovial fluid, 512 T BINDER for perineum, 327 T tube, 283 Talipes equinovarus, 518 Tamponade, cardiac, 178 Tantalum mesh, 148 Tenesmus, 319 Tenosynovitis, 545 tuberculous, 549 Tension pneumothorax, 104 Teratoma, 40 Terramycin. See Antibiotics. Testicle, undescended, 564 Testis, neoplastic disease of, 578 650 INDEX Tests, pregnancy, 587 Rubin's, 606 Tetanus, 15, 630 nursing care, 632 Tetany, 404 Tetralogy of Fallot, 179 Therapy, intravenous, 52 oxygen, 105 radiation, 42 Thoracentesis, 109, 123 Thoracic surgery, 101 Thoracoplasty, 128, 136 nursing care, 138 Thoracotomy, 109 Thrill, 158 Thromboangiitis obliterans, 167 Thrombophlebitis, 97, 164, 598 Thrombosis, 153 Thymus, 407 Thyroid, adenoma, 400 carcinoma, 400 cyst, 397 deficiency of, 396 disease of, drug therapy, 399 use of radioiodine, 403 hormone, 394 neoplastic disease of, 400 operation, 401 physiology of, 394 Thyroidectomy, 401 nursing care, 402 Thyroiditis, 400 Thyroxim, 394 Tic douloureux, 439 nursing care, 440 Tinnitus, 441 Tongue, surgery of, 200 Tongue-tie, 203 Tonometer, 453 Tonsillectomy, 494 nursing care, 495 Tonsillitis, 494 Torticollis, spasmodic, 442 Total care, 5, 99 planning for, 238 Tourniquet, use of, 60 Toxicity of drugs, 33 Toxoid, 16 tetanus, 631 Tracheoesophageal fistula, 217 Tracheotomy, 498 nursing care, 500 Trachoma, 461 Traction, 529 apparatus, nursing care, 535 Transfusion, 63 direct, 65 indirect, 65 Transillumination of sinuses, 481 Trauma. See Injury. Trendelenburg position, 230 Trephine, corneal, 465 cranial cavity, 420 Triage, 20 Trigeminal neuralgia, 439 Trismus, 204 Trocar, 126 Trousseau's sign, 404 Tube-feeding, 50 Tuberculoma, brain, 435 Tuberculosis of bone and joints, 549 of chest wall, 142 of female genital organs, 599 of ileum, 288 of male genital organs, 569, 570 pulmonary, 130 renal, 345 Tumor, 36. See also Neoplastic dis- €OIS62. nomenclature, 39 Two-glass test, 333 Tympanic membrane, 503 Tyrothricin. See Antibiotics. ULCER, corneal, 461 decubitus, 97 duodenal, 250 marginal, 269 pressure, prevention of, 540 stomach, 250 varicose, 162 Ulcerative colitis, 300 Ureteral transplantation, 342 Ureterolithiasis, 346 Urethra, male, injury to, 569 Urinalysis, 333 Urinary incontinence, 341 retention, 340 tract, physiology of, 331 Urine culture, 333 Uterine suspension operation, 610 INDEX 651 Uterus, carcinoma of body, 622 of cervix, 618 myoma of, 615 prolapse of, 609 sarcoma of, 623 Uveal tract, 452 Uveitis, 463 VAGECTOMY, 266 Vagina, deformities of, 604 Valuables, care of, 77 Varicocele, 565 Varicose veins, 162 Vasospasm, 157, 159, 167 Venoclysis, 52 Ventricles of brain, 41 l Ventriculography, 426 nursing care, 429 Vertigo, 441 Vesiculitis, 570 Vincent's angina, 204 Vital capacity, 102 Vitamin K, 284 deficiency of, 59 Volvulus, 290, 306 Vomiting, 235 Vulva, carcinoma of, 614 leukoplakia of, 613 Vulvectomy, 614 nursing care, 614 Vulvovaginitis, gonorrheal, 596 WAR wounds, 20 Waterseal suction, I 18 Welch bacillus, 633 Window operation, 508 Witch's milk, 379 Wounds, 6 cardiac, 178 closed, 9 closure, 14 disruption, 97, 235 healing of, 9 infection of, 23, 27 nursing care of, 21 of esophagus, 213 open, 6 penetrating, 107 puncture, 7, 13 sucking, 108 treatment of, 13 of closed, 19 war, 20 Z-PLASTY, 356 、ſ. ¿? §§§ §§§§ §·