College of S^^v^itima anb burgeons; Hibrarp ^f . Mucous ]\Iembranes, 97 ; The Vagina, 97 ; The Rectum, 98 ; The Blad- der, 99 ; The Urethra, 100 ; The Kidne3S, 100 ; The Stomach, loi ; The Mouth, loi ; The Nose, loi ; Soap, loi ; Brush, 102. V. — Dl.SINFECTION OF INSTRUMENTS AND DRESSINGS IO4 Mechanical Disinfection, 104; Soda-solution, 105; Arrangement of Instruments in the Sterilizer, 106 ; Shape of Instruments, 108 ; Rubber Cath- eters, 109; Instrument-cases, no; Dressing Ma- terial, no; Pre-heating, 113; Sterilizers, 113; Towels, Sponges, Silk, etc., 119; Absorbent Gauze, 121 ; Compressed Moss, 122 ; Iodoform Gauze, 123 ; Salic3dated or Dermatol Gauze, 124 ; Bandages, 124. VI.— Sterilization of Catgut, Silk, etc 125 Sterilization of Catgut, 126 ; Preser\^ation of Cat- gut, 128 ; Unreliability of Catgut, 128 ; Silk, 133 ; Preservation of Silk, 134 ; Thread, 135 ; Silkworm Gut, 136 ; Silver Wire, 136 ; Parch- ment Sutures, etc., 137. VII.— Sponges, Drainage-tubes, and Irrigation Fluid 137 Sponges, 137 ; Gauze, 138; Drainage-tubes, 139 ; Moist Blood-clot, 142 ; Irrigation Fluid, 142. VIII. — The Aseptic Operating-room 143 The Operating-room of a Hospital, 143 ; Wash- basins, 144 ; Glass Shelves, 145 ; Spectators, 145 ; Separate Operating-rooms, 147 ; Micro-organ- isms in the Air, 147 ; The Operating-room in Private Practice, 151 ; Operating-table, 152 ; In- strument-table, 155 ; Instrument-cabinet, 156 ; Irrigators, 156 ; I'ails, 158 ; Baths, 158 ; Wards and Private Rooms, 158 ; Halls and Floors, 158; Beds, Tables, and Chairs, 158; Mattresses and vSheets, 158. IX.— Aseptic Wounds 159 Primary Union, 159; Necrotic Tissue, 160; Buried vSutures, 160; Risks in Occluding CONTENTS. II PAGE Wounds, i6i ; Technique of Uniting Aseptic Wounds, 162 ; Sutures, Continued, 163 ; Relax- ation-, 164; Interrupted, 165; Situation-, 166; Silver-wire, 166 ; Subcutaneous, 167 ; Prophylac- tic, 168 ; Immobilization, 168 ; Aseptic Fever, 170. X. — Infected Wounds 171 Difficulties of Disinfection, 172 ; Cellulitis, or Phlegmon, 173 ; Erysipelas, 173 ; Septicsemia, 173 ; Pyaemia, 174 ; Differentiation between the various forms of Suppuration, 174 ; Symptoms of Infection, 178 ; Suppuration of Stitch-canals, 181 ; Superficial Gangrene, 183 ; Ways of Infec- tion, 184. XI. — Aseptic Open-wound Treatment 186 Presence of Microbes, 188 ; Irregular Cavities, 189 ; Drainage, 191 ; Esmarch Method of Con- striction, 194 ; Splints, 195 ; Partial Union, 196 ; Putrid Wounds, 197 ; Access of Air, 198 ; Moist- ure, 198 ; Antiseptics, 190 ; Immobilization, 200 ; The Sharp Spoon, 205 ; Tubercular Pro- cesses, 206 ; Intestinal Operations. 207 ; Opera- tions on the Liver or the Gall-bladder, 208 ; Mikulicz's Drain, 209 ; Operations on the Pelvic Organs, 210 ; Hemorrhage from the Venous Si- nuses of the Brain, 210 ; Operations on the Kidneys, 211 ; Methodical Packing, 211 ; Resec- tions, 211 ; Drainage in P3^othorax, 212; Drain- age of Bladder, 214 XII. — Renewal of Dressings 214 Removal of Stitches, 215 ; Removal of Sutures, 216 ; Secondary Dressing, 218 ; Secondary Hem- orrhage, 220 ; Abundant Discharge, 223 ; Der- matoses, 226 ; Eczema, 227 ; Necrosis of Wound- margins, 230 ; Cutting Through of the Sutures, 231 ; Ulcers, 232 ; Cavities, 234 ; Compound Frac- tures, 235 ; Pain, 236 ; Temperature, 236 ; Re- dressing, 237 ; Routine in HOvSpital Practice, 238. XIII. — Technique of an Aseptic Operation .... 239 Baths, 239 ; Assistants and Nurses, 240 ; Steril- ized Suits, etc., 241 ; Sterilizing the Dressings, Instruments, etc., 243 ; Anaesthetizing the Pa- tient, 246 ; Procedures Before an Operation, 249 ; Procedures During an Operation, 250 ; Proced- ures After an Operation, 252. 12 COXTEXTS. PAGE XIV. — Aseptic I^7ECTION 253 Preparations before Injection, z^t, ; Morphine, 253 ; Sterility of Solutions, 255 ; Iodoform, 255 ; Emulsions, 256 ; Tuberculocidal Influence of Iodoform Injections, 257 ; Artificial H^'pertemia as an Adjuvant, 25S ; Irrigation Trocar, 259 ; Ethereal Solutions, 262 ; Intraperitoneal Injec- tion, 265 ; Sterilization of Syringes, 265 ; Aseptic Syringe, 267. XV. — An.esthesia 268 Discover}' of the Anaesthetic Properties of Sul- phuric Ether, 268 ; Choice of an Anaesthetic, 270 ; The Inhaler, 271 ; Rules to be Observed in Anaesthesia, 272 ; Accidents during Anaesthesia, 276 ; Deaths during Anaesthesia, 277 ; Artificial Respiration, 279 ; Local Anaesthesia, 282 ; Hy- drochlorate of Cocaine, 283. XVI.— Asepsis in Private Practice 284 Criticisms, 285 ; Ignorance of Aseptic Rules, 288 ; Instruments, 290 ; Instrument-cases, 291 ; Sterilizer, Dressing-material, Sponges, etc., 291 ; Brushes, Ligatures, etc., 292 ; The Operating- room, 293 ; Tables, Chairs, etc., 294 ; Anaesthe- sia, 295 ; Disinfection of the Field of Operation, 296 ; Importance of Asepsis in Office Practice, 297 ; Instruction of the Public, 298. Index 301 INTRODUCTION. With the dawn of Antisepsis there burst upon the surgical world the beginning of a new light — a new era was given to surgery. When a student in Berlin in 1876, the writer one day heard his revered teacher, Von Lan- genbeck, say : " A new method has been ad- vanced by an English surgeon who predicates the principle of wound-treatment upon the de- struction of organic germs, which he assumes to be the cause of wound disturbances. The ex- cellent results claimed by him are not in accord with those we obtain, hence I can hardly grasp their perfection ; yet, notwithstanding my expe- rience, I feel it incumbent upon me to test them in practice." The old master, then reputed throughout the world as the father of joint-resec- tion, did not hesitate to become practically the pupil of young Richard von Volkmann, chief of the Halle Surgical Clinic, who had just returned from London, havino- there studied the methods of Joseph Lister. Von Langenbeck was soon convinced that Listerism was not a phantasm. The curse of centuries was ended. While, 13 14 INTRODUCTION. before antisepsis. So per cent, of all wounds treated at the University Clinic at Munich were affected with hospital gangrene, this disease was now looked upon by the students as a rarity. Formerly, the mortality from amputations reached even 60 per cent. ; thenceforth deaths directly traceable to amputations were the exception. To the perspicacity of those '' to the manor born," and to those who have made America their home, is due the powerful impetus given to the dissemination of this new surgical discovery. Arpad G. Gerster, in his excellent work, was the first to bring Listerism to the front in the United States. The vast benefits it conferred were quickly appreciated in branches of our profes- sion other than that of surgery. Closely follow- ing the vanguard was midwifery, into which im- portant branch of practice antiseptic surgical prin- ciples were soon introduced, for which Henry J. Garrigues deserves special credit. Notwithstanding its unequivocal results, the progressive tendency of surgery did not permit Listerism to rest upon its achievements. The first forward step naturally was directed toward simplifying its complicated methods. This ad- vance movement was primarily manifested in the decadence of the '* spray." The bacterio- logical investigations, in 1 881-1888, of Robert Koch, especially his discovery that the atmo- INTRODUCTION. 1 5 spheric microbes are mainly of an innocuous character, led to the conviction that infection was essentially established by contact. The recognition of this fact gave birth to Asepsis, as a conscientious method whose advent saved wounds from further contact with toxic sub- stances, such as carbolic acid and mercuric bi- chloride. Wounds were found to heal without reaction, as the protoplasm in them was no longer impaired by poisons. Skull and abdo- men were now opened without thought of dan- ger. In the University Hospital of Munich, asep- sis reduced the death-rate in amputations to 2 per cent., while in 1876, the period of early Lis- terism, the death-rate still was 16.1 per cent. The mortality from ovariotomy has fallen from more than 50 to less than 10 per cent. A similar story might be told as to compound fractures, resections of joints, extirpatio uteri, laparot- omies, etc. Amputation of the mammae, an ope- ration that formerly required from four to six months for perfect recovery, now needed but two weeks. Kocher during early Listerism had nine deaths in 12 resections of the intestines; his later records, covering operations made asep- tically, show but two deaths in 13 cases. But it was not surgery alone that was benefited by asepsis : the same strides were made in mid- wifery, as shown by Von Ramdohr's reports of 1 6 INTR OD UC7I0N. 400 births, without a single death, at the New York Post-Graduate Lying-in Asylum. The writer freely confesses that notwithstand- ing he at first had some doubts reeardine the reported results obtained by asepsis in Germany, yet he deemed it expedient to visit, in 1891, among others the clinics of Von Bergmann, Czerny, Schede, and Korte. The results there observed were so strikinor that he was induced to recross the ocean twice afterward to perfect himself in this inestimable art, a detailed descrip- tion of which is given in the following pages. The views and methods described in this vol- ume will undoubtedly change within the next few years, the enormous rush of advancing knowledge relegating to the past for the most part that which to-day is considered incontro- vertible. " Tempora mutantur et nos mutamur in illis" will doubtless apply to asepsis no less than it did to antisepsis. However, one thing is sure: the time of "inspiration" is over. The principles upon which aseptic surgery is estab- lished are firm, since the theories which have led the technique to its present state of perfection are confirmed by bacteriological tests. This change, however, cannot disturb the glorious foundation laid by Joseph Lister. To Lister we owe the mother, A^itisepsis, who, though she died in par- turition, brought forth her idealization, Asepsis. SURGICAL ASEPSIS. I. INFLUENCE OF MICROBES. Sepsis (pri^iQ,, putrefaction) is due to the en- trance and multiplication of microbes in an organism. Asepsis prevents their admission into the human body. To prevent this admission there is requisite a series of procedures, the mastering of which presupposes a perfect know- ledge of the characteristics of microbes. Ene- mies can be combated successfully only when their powers and peculiarities are well known. The significance of man's most virulent ene- mies, the very minute organisms called micro- organisms, warrants detailed consideration of their powerful and peculiar influence upon the living organism. Generally, four classes of mi- cro-organisms are recognized: (i) The fungi or moulds (Fig. i); (2) the sprouting or yeast fungi (saccharomycetes, blastomycetes) ; (3) the fis- sion fungi, bacteria (schizomycetes) — microbes noft e^o^yjv ; and (4) mycetozoa and protozoa. All dead organic substances in contact with 2 17 i8 SURGICAL ASEPSIS. the atmosphere undergo decomposition, or rather fermentation, leading to putrefaction, which is favored by the combined influences of moisture and warmth. Putrefaction, as proved by Th. Schwann, is produced under the influence of micro-organisms which are everywhere present and everywhere adherent. Their vitahty is mar- vellous. They belong to the lowest class of the vegetable kingdom, and are closely allied to the fungi (Fig. i). Botanists term them ''schizomy- cetes." These micro-organisms and their deriva- tives are not only established in any dead organic substratum, but they also, to quote Billroth, under favorable circumstances multiply most rapidly by caus- ing decomposition of the or- ganic substance of their foster- ing soil, and thereby stir up a series of chemical processes w\\\c\\ Jinally lead to division of Fig. I.— Fungi (Penicii- //^^^^ complicated covibinatio7is in- lium glaucum). . , ^,, . . ^ to stniplc7^ ones. 1 his action oi these exciters of decomposition was designated ''fermentation." Their effect, unfortunately, is not dependent primarily upon their quantity, which, under favorable circumstances, may be very small, but by constant reproduction they may so rapidly increase as to cause-decomposition until the soil INFLUENCE OF MICROBES. 1 9 that harbors them becomes exhausted. The rapidity with which microbes multiply is well illustrated by Cohn. He found that a single microbe divides into two within an hour, and subdivides into four at the end of another hour (^Frontispiece, Fig. i). Thus the number derived from a single microbe will amount to 16,500,000 in twenty- four hours. Pasteur classified the microbes under the so- called " organic ferments," to which also belongs the yeast fungus (Fig. 2). To induce fer- mentation it w^ould suffice that the air, or any solid, or a liquid, containinor such microbes, comes . Fig. 2. — Yeast fungi. m contact with a dead organic substance, the fermentation ceasing only when the microbes have consumed all the material required to keep them alive. But, as will soon be seen, microbes can just as well settle in other than a dead organic substance. The atmosphere has been regarded as an important carrier of these organisms. The microbes, suspended in the air, settle in solid and in liquid bodies, and their vitality is destroyed only by a temperature of 212° F. (100° C). The conditions of their in- vasion into the interior of the livine organism are furnished by a break in the continuity of the skin or in the mucous membranes ; while the 20 SURGICAL ASEPSIS. conditions for the development and multiplica- tion of the microbe that has invaded or has been brought into the organism prevail wherever there is a favorable soil. Microbes grow best in a temperature varying from 86° to 98° F. Fully thirty years ago, Pasteur and Billroth recoofnized the decided influence of micro-oro-an- isms upon wounds and inflammatory processes. Lister carried these theoretical investioations into practice. After many erroneous views were corrected, Robert Koch succeeded in isolating cer- tain forms from the enormous quantity of micro- organisms known, and in cultivating them sepa- rately on artificial soil. Thus it became possible to study their influence upon living tissues, and to demonstrate their presence therein by charac- teristic reactions made evident by staining. It was discovered not only that fermentation in dead substances was caused by organic germs, but also that a whole series of pathological pro- cesses in the living organism, locally as well as generally, were due to invasion and multiplica- tion of specific microbes. While the ferment germs were formerly regarded as the cause of the peculiar complications in wounds and in in- flammatory processes called "accidental wound- diseases," it is now a well-established fact that, besides these germs many varieties of micro- orofanisms exist which have no connection with INFLUENCE OF MICROBES. 21 fermentation, but which cause a decided influence upon the Hving organism. It has been proved that certain species of microbes cause inflammation, that other species cause suppuration or gangrene, and that the most serious compHcations in connection with wounds and inflammatory processes — that is, the most frequent and deleterious acute and chronic diseases — are due solely to microbic infection. Microbes, according to the conditions essential to their life, are of two kinds : (i) Pathogenous or parasitic microbes, which develop and multiply only within living organ- isms. (2) Saprophytes or nonpathogenous microbes, which depend upon nutriment obtained within dead tissue. The pathogenous microbes are either {a) facul- tative (occasional), depending but partially upon nutriment obtained within living organisms, or [b) obligate (real), which entirely depend for their existence upon the soil found within living animal organisms. Only some of the obligate parasites can be cultivated on artificial soil. The action of these parasites is not the same in all species of animals. One kind of micro-organism may produce intense specific effects in one species of animal, for which it may be pathogenic, while upon another it may 22 SURGICAL ASEPSIS. not exert the slightest influence. The so-called ''saprophytes" have no influence whatever upon living human tissue, but they may do consider- able harm bv settlins: in necrotic tissues and in exudations. The saprophytes should not be confounded with the pathogenic microbes, which produce specific processes wdthin living tissue. The latter micro-organisms appear in three w^ell- characterized forms— ^namely: (i) The .*. •* •*. micrococcus [(itxpog, small ; 6 xoxxog, the **•'/': kernel) or coccus, which presents a Fig. 3.-Cocci. spherical form (Fig. 3) ; (2) the bac- termm (ro (BaxTy^piov, rod) — in the re- stricted sense of the word — or bacillus (a little rod or staff), or staff-shaped micro-organism '^^ 3 ..>■■ Fig. 4.— Bacilli. Fig. 5.— Spirillum (relapsing fever). (Fig. 4) ; and (3) the spirillum (amtpfx, a coil), or spiral-shaped micro-organism, which has the ap- pearance of a spirally-twisted thread (vibrio, spiro- chaite ; Fig. 5j. lliese expressions do not indicate INFLUENCE OF MICROBES. 23 a decided species, but denote only the morpho- logical character of micro-organisms, the different forms of which can be compared best with (i) a billiard-ball, (2) a lead-pencil, and (3) a cork- screw. Their better comprehension demands qualification, such as micrococcus pyogenes, bacil- lus antlu^acis, etc. It is customary now to use the term "bacterium" synonymously with "mi- crobe," and not with "bacillus," which would be the "bacterium xojr I'^oj/iv!' The cells of the microbes present two essen- tial parts — namely, the nucleus, and the surround- FiG. 6. — Streptococci. Fig. 7. — Coccoglia. inor membrane called the "cell-membrane" — both of them beinor enclosed in a orelatlnous cover. The substance of the nucleus consists of proto- plasm, w^hich has the peculiarity that it can be stained by aniline dyes, while the elastic mem- brane is composed of a substance closely related to cellulose. The membrane is distinguished by its peculiarity of swelling in water. Cocci and bacilli are either Isolated or adherent to each other, or they form chains of from four 24 SURGICAL ASEPSIS. to twenty or more rows (streptococcus, strepto- bacterium, from 6 Qn^iitrbq, the chain ; Fig. 6), or tliev are acro-lomerated in irregular olobular and cyhndrical forms by masses of mucus (coccogHa, Yi y?aa or y?.0La, the glue ; Fig. 7) ex- creted by themselves (staphylococcus, ascococcus). The globular elements differ markedly in size. Fig. 8. — Flagellate bacilli (typhoid). They are sometimes as large as a cell-nucleus, or they are equal to the diameter of a globule which can barely be perceived by the strongest magnifying power. They are sometimes mov- able, sometimes quiescent. The bacilli are of various lengths. Some are so short that they might be mistaken for cocci ; the INFLUENCE OF MICROBES. 2$ longest ones equal 20^^ in length. Their thick- ness is very irregular. Some forms show lively motion in the " migratory stage," induced by their flagella, or thread-like appendages (Fig. 8). Most species of micro-organisms grow only as cocci, bacilli, or spirilli. Besides these species there are others which vary widely in form during their development. In the quiescent state the or- ganisms either remain isolated or they unite into so-called "colonies" (zoogloea, Frontispiece,V\g. 2) showing peculiarities that are very important in differentiating the species. Multiplication of micro-organisms takes place either by division — that is, one cell splits into two or more similar ones — or by the formation of spores. As stated before, micro-oro^anisms are found as well in foul or fermentinor substances as in the living organism. But they prosper only under the following conditions: i, they re- quire water in large quantities ; 2, they need nitrogenous combinations for their assimilation ; 3, they must have a comparatively high tem- perature (the most favorable temperature being that of the blood). They separate the complicated organic constituents of their fostering soil into a series of much simpler substances, during which process CO2 is formed and warmth is evolved. This transformation is due to the action of the living protoplasm of the micro-organisms, which 26 SURGICAL ASEPSIS. substance probably, like a ferment, Is able to seereeate a ereat amount of suitable soil. The products of this change of matter are numerous and are but partially known. They change fre- quently, according to the form of the microbe and the character of the soil offered. Most fre- quently hydrosulphuric acid, carbonic acid, car- buretted-hydrogen gas, hydrogen, ammonia, water, alcohol, citric acid, aromatics (phenol, tyrosin), and peptones are formed. In addition, many microbes produce ferments ; others — and surgically they are the most important — form different substances, known as ptomaines (tox- ines, toxalbumins, cadaver-alkaloids, leucomaines), which exercise a virulent influence upon the liv- ing organism. These toxic products were detected first in foul liquids and then in decomposing hu- man cadavers. They are bases containing nitro- gen ; they very much resemble vegetable alka- loids ; they are in part products of tissue-meta- morphosis in microbes ; but it is now known that they are especially produced by microbes within living tissues. Bergmann and Zuelzer obtained virulent extracts from decomposing mixtures, and Brieger and Nencki, who produced a whole series of ptomaines, ascertained the combination of their chemical elements. Thus are known some indifferent and some virulent alkaloids which originate in the human cadaver, begin- INFLUENCE OF MICROBES. 2 7 ning on the third day after death. Further- more, it is known that some alkaloids are formed by specific pathogenic microbes. A knowledge of the chemical substances produced by various forms of microbes in their cultures is of the most vital importance, as in most instances local as well as general effects depend upon them. Whenever necrotic tissue or a fluid — for instance, a bloody effusion — is present in a living organ- ism, microbes may develop, while the healthy physiological tissues remain very resistant. According to Pasteur, microbes should be di- vided into ah'obic, those which live best in oxygen, and anaerobic, those which not only live without, but generally die in, pure oxygen. Both forms produce decomposition. When an organic fluid is exposed to the free atmosphere, it becomes turbid, because the microbes w^hich fall into it from the air rapidly multiply ; a priori only the aerobic microbes do so. They quickly consume all the oxygen contained in the liquid, and as soon as they have accomplished this they must die and settle to the bottom of the liquid in the shape of a muddy sediment. Some may continue to live on the surface of the fluid, where thev obtain partial nourishment from the atmosphere, and where they form a membrane which gradually thickens and prevents access of oxygen to the liquid and to the organisms held in suspension. 28 SURGICAL ASEPSIS. Then the opportunity arises for the anaerobic microbes [luicrobes de la putrefaction, Pasteur) to cause a transformation of the combinations of nitrogen into much more compHcated sub- stances. These substances ao^ain are so de- composed by the aerobic microbes that they attract oxygen, and while decomposition pro- gresses further the united action of anaerobic and aerobic microbes finally liberates the last products of decomposition — namely, water, car- bonic acid, and ammonia. Some micro-ororanisms are found in so-called "putrid processes," while others occur in tissues and in fluids which do not show the slig^htest trace of decomposition — for instance, in abscesses which have not been exposed to the atmosphere at all. Hence it must be assumed that the real decomposing microbes cause only a part of those changes which are ordinarily considered the con- sequence of infection. As shown before, it is necessary to distinguish between real sapro- phytes and microbes xar' i.^oyyiv — that is, be- tween septogenic and pathogenic organisms — although this distinction is only relative. While saprophytes which will settle on wound-surfaces and in cavities, as in the necrotic endometrium of a puerperal uterus or in the intestines, originate ptomaines, the absorption of which would be fol- lowed by toxic effects upon the living organism, INFLUENCE OF MICROBES. 29 the pathogenic microbes find the most favorable conditions for their development and multiplica- tion in living tissue — that is, inside of cells, in the blood, in the lymphatics, etc. By thus invading the system they cause a series of disturbances. These pathogenic microbes differ essentially from the decomposing micro-organisms, and are killed by them in dead tissue. Hence decomposition, strange to say, is itself the most effective anti- parasitic agent to overcome the action of such microbes. Fig. 9. — Staining the bacillus tuberculosis. No scientific method of isolating and cultivat- ing a distinct species from a mixture of these different microbes was known until Robert Koch discovered the mode of disseminating a mixture of them over a laro-e surface in order to favor the development of the various species. Then the different forms of vegetation could be recoe- nized with the naked eye as spots or turfs of a peculiar shape, color, growing species, etc. On an 30 SURGICAL ASEPSIS. artificially prepared soil, especially on gelatin or on agar, pure cultures can readily be obtained. Some of them are characterized by their capacity to liquefy the gelatin, while others form white dry heaps or white mucilaginous drops, or form colonies of a yellow, green, or red color. A very important aid in distinguishing these different forms under the microscope is their staining (Fig. 9) with certain coloring matters, es- pecially aniline dyes, and the so-called " Abbe's illumination," a method which allows a distinct Fig. 10. — Making gelatin cultures. ocular perception of the stained microbes. Koch's investigations are based upon the necessity of cultivating these species pure ; that is, they must be free from all accidental admixtures. In order to obtain this purity in cultivation a small quan- tity of the substance containing the microbes is implanted upon some suitable liquid soil, meat or agar-agar gelatin, to which peptone is added, being generally preferred (Fig. 10). Hie soil must INFLUENCE OF MICROBES. 31 first be freed from all foreign microbes — that is, it must be sterilized — and then the cultivation must be conducted in an incubator (Fig. 11). From Fig. II. — Incubator. Fig. 12. — Puncture culture ( Micro-organisms. — 1-3. Anthrax bacilli: i, cover-glass preparation: 2, from the spleen of a mouse ; 3, from cultures on a Petri plate. 4. Anthrax bacilli with spores, from a gelatin culture. 5. Anthrax cultures. 6. Cultures of typluis bacilli. SURGICAL AvSEPSIvS. Plate III. \ \ V \ 5 H MiCKO-ORGANisMS. — I. Eacillus of maligiumt oedema, from oedematous serum. 2. Cultures of the bacillus of malignant oedema. 3. Diphtheria bacilli, from a diphtheritic membrane. 4. Diph- theria bacilli, from an agar culture. 5. Bacillus of mouse-septicsemia, taken from blood. 6. Cul- tures of mouse-septicaemia. INFLUENCE OF MICROBES. 45 superficial layers of ordinary garden soil and in the dirt and dust of carpeted floors. It has the length of the anthrax bacillus, and possesses con- siderable power of motion, which is produced by its flagella. Colonies liquefy gelatin. As it is an obligate anaerobe, it can be cultivated only when the atmosphere is excluded. Men as well as animals are susceptible to this bacillus, which Fig. 17. — Strings of anthrax bacilli. can be stained with cold aqueous dyes. It can be decolorized by the method of Gram. The bacillus dipJitJierice (PI. III., Figs. 3, 4) was discovered by Lofl^er. Roux, Escherich, Brie- ger, and Fraenkel produced true diphtheria by transferring cultures upon the opened trachea of rabbits and guinea-pigs. The bacillus diphtheriae is a straiorht or slio^htlv bent rod of the size of the tubercle bacillus. It is not movable, does not contain spores, and does not liquefy gelatin. It 46 SURGICAL ASEPSIS. can be stained with alcoholic aqueous dyes and by Gram's method. Other microbes, like the bacterium lactis aerog- enes, the bacillus leprae, of rhinoscleroma, of mal- leus, and of typhus, the vibrio cholerse Asiaticae, and the spirillum of recurrent fever and of mala- ria, are of comparatively little importance so far as concerns their direct interference with wounds. One of the most interesting non-pathogenic bacilli is the bacillus prodigiosus (PL I., Fig. 6), which is found sometimes on moist bread, pota- toes, or in milk. Its cultures produce a red color, which has been the foundation for the legends of the bleeding bread, the bleeding holy wa- fers, etc. A peculiar fungus Is the actinomyces (ray fungus, actinomyces bovis s. hominis; Figs. i8, 19), discovered as early as 1845 by B. von Lan- genbeck in a vertebral abscess of a man. It used to be classed among the hyphomycetes (mould fungi), but is now regarded simply as a variety of schizomycetes. Its favorite domicile is the maxillae of catde, where it causes indurated tumor-like masses which undergo softening and suppuration. In man the lower jaw (Pig. 19) also is most frequendy the primary focus of this malignant disease, which extends continuously into the adjacent tissue and to internal organs, as the lungs, the pleurie, the heart, the liver, the INFLUENCE OF MICROBES. A7 kidneys, the intestines, and the brain. The acti- nomyces can be cultivated on agar by cutting- off oxygen, in which event yellowish-white colonies are formed ; but if the air has free access an ochre-colored appearance is obtained. Pure cul- tures injected into the cavum peritonei of rabbits Fig. iS. — Actinomyces. Fig. 19. — Actinomycosis. produce typical actinomycosis. The fungus stains well with the ordinary aniline dyes and by the method of Gram. The human body may be invaded by these micro-organisms through solutions of continuity either of the skin or of the mucous membranes where the microbes fall directly upon them. As a rule, however, they are transferred or are inoc- ulated by other substances to which they adhere — ,48 SURGICAL ASEPSIS. that Is, by the wounding instrument, by the fingers, by clothing, or by unclean wound-dressings. The hair-follicles and the sebaceous follicles may also be factors in this process. In view of recent investigations, it seems more and more positive that the air has no bearing upon infection, but that contact is all-important. In other words, the millions of micro-oro-anisms suspended in the air and which may invade a wound are usually innocent and of an Indifferent character. Were this otherwise, it would be im- possible to perform laparotomies and similar seri- ous operations in large surgical amphitheatres (where several hundred students are present) with the same success as is clone in operating- rooms, where the walls, floors, and ceilings are constructed of marble, and where, besides the patient, none but the operator and his assistants are present. Lister originally thought that the atmospheric micro-organisms causing decomposition in organic substances are identical with those that infect woynds ; therefore he regarded the air as the most Important enemy to be combated. For this purpose he very naturally advised his spray. Nowadays diametrically opposite views are held ; that is, the air is deemed the most unfavor- able place for these micro-organisms, It having been proved that most infecting microbes of SURGICAL ASEPSIS. Plate IV Microscope with Abbe's apparatus. INFLUENCE OF MICROBES. 49 wounds are destroyed shortly after they reach the atmosphere. When no solution of continuity of the tissue is present, it has been supposed that probably the pyogenic cocci enter through the mucous membranes of the respiratory or the digestive tract, and that migratory cells contain- ing microbes invade the lymph- and blood-circu- lation by migrating through the mucous mem- brane. It was further assumed that they might then establish themselves at any point in the system, and there develop and multiply. At the German Poliklinik the writer observed a typical cause of swollen and suppurating glands, which condition he generally designated as " dirt inflammation." Some classes of immigrants, com- ing from semi-barbarous districts, regard even an annual bath as an extravagant and foolish luxury, and carry all imaginable varieties of mother earth, especially on those surfaces of the body not cov- ered by clothing. When they scratch themselves — for obvious reasons — they become self-inocu- lated with the microbes harbored in their well- cultivated filth.' As bacteriological investieations proved, in most of these cases the staphylococcus pyogenes aureus, sometimes the staphylococcus (epidermidis) albus, was found. Locally the microbes rapidly multiply and find ^ " Surgical Diseases of the Neck," Neio York Med. Journal, April 29, 1893. 4 50 SURGICAL ASEPSIS. their way into the connective-tissue cells and the walls of the blood-vessels. Within twenty-four hours exudation and emigration start as direct consequences of the so-called ''phlogosin " (Leber) caused by the microbes. The white blood-corpuscles are attracted by the microbes and take them up into their proto- plasm precisely as they might take up pigment, transporting them into the tissues by their active locomotion. The leucocytes and microbes accumulate more and more, while cellular infiltra- tion and germ-formation progress toward the periphery. Within two or three days softening and breaking up of the tissues take place in the centre of the focus of the inflammation ; in brief, an abscess forms. There are still some weak points in the above explanation of the origin of pus-accumuladon, as, besides those described above, there are present other micro-organisms which may be of some importance in this connection. Buchner, for instance, in examining seventeen forms of bac- teria, found a substance that he called " bacterio- proteine," which he deemed the real cause of suppuration. This substance, he claims, is set free only when the bacteria are dead. The question then arises : Are the bacteria in an abscess alive or dead ? In other words, is suppuration caused by the vital manifestadons of INFLUENCE OF MICROBES. . $1 bacteria, or by such substances as form only after their death ? Every abscess contains nu- merous staphylococci or streptococci, either alive or dead. But, besides these organisms, there may be present other forms of micro-organisms, which perhaps remain unrecognized because of the present defective means of cultivating them. At any rate, it can hardly be conceived how staphylococci or streptococci alone can cause a series of very different diseases ; how strepto- cocci of endocarditis, for instance, should be the origin of rheumatism, of tonsillitis, of osteomye- litis, of cerebro-spinal meningitis, of cryptogenetic pyaemia, of septicaemia, of carbuncle, etc. Can it, then, really be true that an innocent tonsillitis has the same origin as cerebro-spinal meningitis, and that only the difference of the microbes' scenes of action furnishes the variation in their significance? Reger ' advances the theory that most infec- tious diseases, especially the so-called " pus-dis- eases," are nothing but the local expression of general infection caused by a great number of different micro-ororanisms. Similar views are o expressed by Heim.'' The course which infec- tious processes take is supposed to be influenced by the disposition of the patient, by the oppor- ^ Verhandlungen der deutschen Gesellschafi fur Chinirgie, XXIII. Con- gress, 1894. " Lehrbuch der bakieriologischen Untersiichwig und Diagnostik, Stutt- gart, 1894. 52 SURGICAL ASEPSIS. tunlty offered by his locus mifioris resistentice, and by the predilection of the different mi- cro-organisms for one place or another. Reger distinguished two different typical groups of infectious diseases : (a) Specific contagious dis- eases : measles, rubeola, parotitis, varicella, diph- theria, scarlet fever, influenza, pneumonia, ery- sipelas, and conjunctivitis; (/5) Pus-diseases : ca- tarrhs and inflammations of the mucous mem- branes of the respiratory and digestive tracts, the anginae, the inflammatory organic diseases, rheumatism, inflammatory processes of the skin- surface, and diseases which are accompanied by suppuration or by the formation of serum, fibrin, or muco-pus, and which are dependent upon direct contact with pus or dirt, upon the influence of an external climatic noxiousness, or upon a certain diathesis. In the progress of these pus- diseases Reger found exactly the same regular course as in the other group of infectious dis- eases. He therefore concludes that the usual classification of all diseases has up to the pres- ent been wrong, and that these diseases were all named either after their most predominant symptom or after the organ which is most involved, instead of being named after their true orio-inators, the microbes. The whole classifica- tion customary through centuries could be due only to our ignorance of etiology. THE IMPORTANCE OF ASEPSIS. 53 It is thus seen that there are still many import- ant questions awaiting elucidation, which can first and foremost be given by bacteriological experi- ments. Surgery especially has made such won- derful advances within the past twenty-five years as to justify great enthusiasm for the results of the science in the near future. The main requi- site for its further development will be the crea- tion of surgico-bacteriological laboratories. The experience gained by abundant surgical material will then go hand in hand with all the advances of modern chemistry and bacteriology, forming a new and extremely useful combination. II. THE IMPORTANCE OF ASEPSIS. Asepsis is the offspring of antisepsis. Both methods tend to the same end. At the present time it is very difficult to draw a line of demar- cation between them, much more so as treat- ment cannot strictly be aseptic without employing means of disinfection — that is, following antU septic principles to a certain extent. Antisepsis, in the original acceptation of the word, was supposed to mean a method of pre- venting fermentation or putrefaction. The result obtained by observing its rules would be asepsis. An aseptic wound was originally deemed one which was so well disinfected by antiseptics that 54 SURGICAL ASEPSIS. no putrefaction could take place in It ; but at present the word asepsis is generally employed in contradistinction to antisepsis. Instead of striving to kill microbes brouoht into contact with a wound by the use of more or less poison- ous chemical procedures, the endeavor is now to keep the wound free from microbes without em- ploying so-called ''germicidal" chemical agents. Whenever chemical substances can be avoided during an operation, physical methods of disin- fection are substituted. Thus the aseptic method is by its nature more of a prophylactic, as well as more of a non-poisonous, character than origi- nally was the antiseptic. An aseptic wound is supposed, on the one hand, to be a wound which has not first been infected and then freed from micro-organisms by disinfection ; on the other hand, it is Impos- sible to conceive among aseptic paraphernalia articles that have never been brought into con- tact with micro-organisms, such as instruments, operating-tables, operating-rooms, etc. Here the aseptic designation signifies only that the articles employed can easily be rendered aseptic. For in- stance, an instrument havino- a metal handle can more readily be made aseptic than one whose handle consists of wood or of hard rubber. Recent investigations by Robert Koch, E. von Bergmann, Schimmelbusch, Schlange, Riedel, THE IMPORTANCE OF ASEPSIS. 55 Neuber, Tait, Koeberle, Geppert, Miguel, Redard, Fraenkel, Nissen, Schaeffer, Behring, Gerloczy, New, Laplace, and others clearly show that the so-called " orermicidal " chemical substances do not possess the disinfecting power that was long attributed to them. This over-estimation is due to the former mistake of transferring small quan- tities of the antiseptic fluid to the culture soil at one time. A piece of gauze, tested as to its ster- ility, will serve as an illustration. If the gauze is put on suitable soil and a small quantity of an antiseptic fluid is transferred with it, the soil be- comes impaired and the microbes naturally fail to multiply. Koch divided the object to be disinfected — for instance, infected silk thread — into minute por- tions, while the soil represented a considerable area, with a view to great dilution during culture. This experiment was followed by surprising re- sults. The bacillus of anthrax retained all its vitality even after being exposed for two weeks to the influence of a 5 per cent, solution of car- bolic acid. Similar results were obtained with strono; bichloride solutions. Even the most liberal irrigation with bichloride of mercury did not necessarily prevent sepsis. This drug, which was supposed to be the strongest antiseptic, does not destroy bacteria with certainty. More- over, as all antiseptics more or less impair the -56 SURGICAL ASEPSIS. tissues of wound-surfaces, their resistance to the microbes is weakened. But, despite all these disadvantages, it would have been unjustifiable to dispense with anti- septic solutions so long as they were cred- ited with positive and rapid germicidal power. Thanks to very careful application of such solu- tions in the hands of great masters, these disad- vantages have been counterbalanced by their advantages. That Lister himself appreciated these disadvantages is manifested by the fact that even at the time of his first publications he advised a series of precautions regarding the use of carbolic acid, which he characterized as a disagreeable necessity, especially because of its irritating action on the tissues. United aseptic wounds heal much more quickly than wounds washed with antiseptic solutions. In the former, suppuration and other disturbances are observed only exceptionally; secretion is also much more scanty, thus render- ing drainage unnecessary. Poisoning with such drugs as carbolic acid, bichloride of mercury, iodoform, etc. need not be feared, as they are not required in united wounds. Dressings do not require such frequent changes as formerly, and asepsis is far more economical than antisepsis. The advantages of asepsis are manifest espe- cially in operations on the peritoneum, which THE IMPORTANCE OF ASEPSIS. 57 seems to react more readily to the application of antiseptic solutions than any other organ. Therefore these strong and most desirable drugs cannot be employed within the abdominal cavity, as the great tendency toward absorption, which is another characteristic mark of the peritoneal membrane, would favor general poisoning. If infection by contact has been prevented before- hand — that is, if all objects which touch the peri- toneum during an operation are freed from micro- organisms — the abdominal cavity may safely be closed. No septic agent will remain in the cavum peritonei, and all microbes that may have fallen into the cavity from the air are innocent (compare the experiments of Petri and Cleves- Symmer, p. 147), and will be kept in check by the living tissue itself. No reaction, as a rule, follows laparotomies per- formed aseptically, and even inflammatory pro- cesses, which are frequently observed after the use of antiseptic solutions, appear only under the most exceptional circumstances. The same con- ditions, especially absence of reaction, are verified in carrying aseptic principles over to other healthy (non-infected) tissues. Asepsis proves to be so far superior to anti- sepsis that the method to be carried out has ceased to be a matter of choice. // is simply the duty of every surgeon to substitute asepsis for anti- 58 SURGICAL ASEPSIS. sepsis, and to titilize the latter only as a part of the astptic viethod. Aseptic maxims were more or less conscien- tiously advanced by Czerny, Neuber, Tait, and others. Czerny as early as 1877 boiled his silk ligatures. The splendid results obtained by Neu- ber, Tait, and others by the observation of the ordinary principles of cleanliness are universally known. But evidently ideas on the subject of asepsis had occurred long before ; they apparently date back to before the Christian era, when some of the principles of asepsis were more or less con- sciously carried out. Much of the admirable knowledge of the great Hippocratic era was lost during twenty-three centuries. Is it not aston- ishing that Hippocrates laid great stress upon frequently washing the patient with warm water before performing an operation ? Does not this extraordinary cleanliness appear like the dawn of aseptic principles? Is it not an explanation of the success of operations so signally performed at that period that some are inclined to doubt the authenticity of the records? It would suit the spirit of our sterilizing age to be reminded of the frequent washings by the Jews — a religious rite ordained by Moses, who doubtless was one of the greatest judges of human requirements. A slight indication of what must have been lost of the immense knowledge of the school of THE IMPORTANCE OF ASEPSIS. 59 Kos, and of how advanced Roman surgery must have been, may be gained by visiting *' the house of the surgeon" at Pompeii. The streams of water constandy flowing through the streets of Roman cities were certainly apt to remove mi- crobes. Furthermore — and the writer is not aware that it has ever been mentioned from this point of view — the laree number of small wells in the ''house of the surgeon" suggests at least some vague knowledge of the principles of asepsis. At a recent visit to this most interesting place the writer instinctively felt more than ever before how little advanced in many respects is the pres- ent age when compared with the medical civil- ization of many centuries ago. Why should not the ancient surgeon, with his fine art of diagnosis and with his powerful weapon " cleanliness," have obtained better results than the suro-eon of not many years ago, who went directly from the autopsy-room, after having washed his hands superficially with soap and water, to the oper- ating-room, repeating his anatomical master- piece on the living subject, which w^as thus fre- quently made a specimen for the autopsy-room? The instruments excavated at Herculaneum and at Pompeii, and now exhibited in the Vatican at Rome and in the Museo Borbonico at Naples, are all of the most admirable perfection ; being made of steel or of bronze, they are aseptic. 6o SURGICAL ASEPSIS. Clear and conscientious aseptic principles, however, date only from the time Robert Koch's genius created their scientific base by testing the value of our disinfecting means by bacteri- olocrical investicrations. On this bacteriological foundation Kuemmell, Fuerbrinorer, Von Bere- mann, Schimmelbusch, Braatz, Saenger, Tripier, Kelly, and others were able to elaborate the prin- ciples of their standard methods. III. MEANS OF DISINFECTION. It is undeniable that microbes have been found in wounds that have healed without the slightest reaction. Hence it must be assumed that infection does not necessarily depend upon the invasion of a single microbe, but that it depends upon the quality or the quantity of microbes present. Killing microbes is certainly the safest manner of preventing their deleterious influence upon wounds. Various ways of accomplishing this extermination are known : some methods are to destroy the microbes directly, to prevent their development and multiplication, or to remove them mechanically. Nothing definite can yet be said as to the value of other methods, such as the employment of so-called "anti-toxic" sub- stances, or of such medicaments as, it is alleged, MEANS OF DISINFECTION. bl deprive the micro-organisms of their virulence, or of procedures directed to rendering the sys- tem immune ao^ainst the invasion of microbes. Sunlight also possesses disinfecting power. Arloing found that anthrax spores cultivated in bouillon died in a few hours on being exposed to direct sunlight. Koch saw cultures of tuber- cle bacilli die out in from five to seven days by simply placing them at a window. This would explain why simple laparotomy is apt to cure peritoneal tuberculosis. Spllken, Gottstein, and Krueger found that electricity is able also to destroy microbes. The most effective, and therefore the most im- portant, means of disinfection is the mechanical method^ which may safely be said to be at least three-fourths asepsis. It is accomplished by re- moving all dust and dirt by the use of brushes, a nail-cleaner, etc. Manifestly, if the micro-organ- isms are thus brushed off, they do not require any more disinfection ; vice versa, dirt under the finger-nails, no matter how long kept in a strong antiseptic solution, contains sufficient micro-or- ganisms of ample vitality to produce infection if the mechanical cleansing process is not thor- oughly carried out Therefore any question as to the greater and lesser virulence of such micro- organisms as can mechanically be removed Is entirely Irrelevant. The value of the so-called 62 SURGICAL ASEPSIS. "bactericidal" methods of disinfection depends upon the proofs furnished by culture-tests as made by Koch. In addition to the points alluded to in Section I., on the "Influence of Microbes," one further factor demands consideration — namely, the pres- ence of spores, whose vitality differs materially from that of other orofanisms. Oro-anisms con- taining spores, such as the anthrax bacilli, are more difficult to destroy than are those organisms which do not contain spores. While a 2 per cent. solution of carbolic acid is apt to kill the bacillus of anthrax in one minute, the spores of the same bacillus are not influenced by a 5 per cent, solu- tion of carbolic acid, even if they are kept in it for weeks ; therefore the bacilli must necessarily be well distinguished from the spores. The following microbes contain no spores : the streptococcus pyogenes, the streptococcus ery- sipelatis, the staphylococcus pyogenes aureus, albus, and citreus, and the bacilli of diphtheria and of malleus. The following bacilli contain spores : the bacillus tuberculosis, anthracis, and tetani. Tetanus spores are more easily destroyed than are those of anthrax or of tuberculosis. In practice they may ordinarily be left out of con- sideration as regards wound-disinfection. What is needed, as a rule, is to prevent the contact espe- cially of such cocci as the staphylococcus pyo- MEANS OF DISINFECTION. 63 genes and the streptococcus pyogenes or eryslpe- latis with wounds, instruments, dressings, etc. As the development and multiplication of micro- organisms is predicated upon a favorable soil with a certain temperature and quantity of moisture, their vitality very naturally can be destroyed by depriving them of these essentials. This depri- vation can be effected by chemical substances as well as by heat, which may be utilized as steam, as hot air, and as boiling water. The last men- tioned is the most powerful germicidal agent of all. Heat, by the way, was employed by Hip- pocrates and Oribasius, who recommended using the hot iron and boiling oil upon wounds, not only to arrest hemorrhage, but, as is maintained, also to cleanse. The picture showing Ambroise Pare in the act of cauterizing with a hot iron the amputation- wound of a soldier's leg is well known. Recently, M. G. Phocas of Lille, Felizet,' Dreesnau,^ and M. Feannel^ recommended the flame of a gas-jet for sterilizing wounds, or the pouring of oil into the cavities and bringing it to the boiling-point by a hot iron, or simply the touching of the wound- surface with boiling water. The latter procedure appears to be the most rational among those ^ Bulletin de la Chinirgie, 1 892. ^ Centralblatt fii)' Chirurgie, 1893, No. 3. ^ Gazette des Hopitaux, Nos. 59 and 62. 64 SURGICAL ASEPSIS. named, as certainly it Is the least injurious to the tissues. Boiling water destroys all forms of cocci in from one to five seconds, and the spores of the bacillus anthracis in two minutes. Steam destroys the spores in fifteen minutes, while tubercle bacilli require twenty minutes. A o.i per cent, solution of bichloride of mercury fails to destroy the spores of the bacillus anthracis in twenty-four hours ; chlorine, iodine, and the cresols are equally powerless. A 5 per cent, solution of car- bolic acid, as also the coal-tar derivatives, requires much longer ; even chloride of calcium destroys the spores of the anthrax bacillus only after five days', and ether after thirty days', immersion. In view of these statements, the exactness of which can no longer be doubted, it is surprising that with 2 per cent, solutions of carbolic acid comparatively good results were, and are still, obtained, and that many surgeons continue to express their great satisfaction with, and their abiding faith In, this drug, and therefore seek no change. Yet it is beyond cavil that these so- called " satisfactory " results are due, not to the influence of a weak solution of carbolic acid poured upon the instruments a few minutes before operation, but to conscientiously ioWo^^ \x\g aseptic principles, the fundamental one of which is the thorough mechanical cleansing of instruments, the surgeon's hands, and the field of operation. MEANS OF DISINFECTION. 65 If an abscess has been incised, it cannot be expected that the knife, after having remained in a solution of carboHc acid for a few minutes, or even for an hour or more, becomes so well disin- fected that it may safely be used for a subsequent plastic operation or for opening a similar abscess. Even if the knife was cleansed mechanically be- fore beinor immersed in the solution, it would perhaps require many hours to render it aseptic. Manifestly, no surgeon can wait so long. But if he simply dips the knife into boiling water for two minutes, he is absolutely sure of its being perfectly aseptic. If, then, boilirig water is so superior to all chemical substances, so far as concerns the certain as well as the quick de- stj'uction of microbes, it should be substituted for these substances whenever possible. The addi- tion of soda (i : loo) prevents the rusting of the instruments and increases the disinfecting power of boilinor water. A further orreat advantage of this method of disinfection is its simplicity and small expense. As shown in Sections VIII. and XVI., boiling water in an ordinary kitchen pot, and the addition of a tablespoonful of soda, which may be found in the poorest tenement-house, are all that are re- quired for thorough disinfection. In a similar way the dressings may be rendered aseptic. The difficulty of impregnating gauze, cotton, or other 66 SURGICAL ASEPSIS. dressing material with chemical substances, If orlvcerin or fatty or resinous inoredients are not added, is well known. All these constituents necessarily diminish the absorbent power of the dressinor. It has always been the general aim to add so- called "antiseptic" substances to the gauze, to prevent decomposition of the discharges from wounds into the orauze. No chemical substance has been found that acts so powerfully in this direction as dryness. Dryness is one of the three important enemies of bacteria, as above stated. Exposing bacteria to dryness deprives them of moisture, one of the conditions necessary for their life. Only in cases of very severe Infection, where thick and putrid secretion (ichor) Is present, can the principle of drying not be carried out ; in which cases the surgeon may rely upon another enemy of bacteria — anaerobiosis (see p. 27). Anaerobic microbes, as a rule, die In pure oxy- gen, while aerobic microbes multiply in oxygen, but die when deprived of it. In wound-cavities oxygen Is absent ; therefore in such a cavity anaerobic microbes find favorable conditions, while if the cavity be exposed by large incision, thus freely admitting oxygen, an- aerobic microbes will necessarily be destroyed. These well-proved facts form the bacteriological MEANS OF DISINFECTION. 6'J basis of the open-wound treatmefit, to which the surgeon must resort in cases of infection fp. 176), and which will be discussed in Section XI. If gauze be exposed to a jet of steam for twenty minutes, all microbes are destroyed. Ordinarily, such gauze is superior to impregnated gauze, on account of its much greater absorbent power. Furthermore, it is very questionable if all the dressings containing bichloride of mercury, car- bolic, salicylic, or boric acids, iodoform, or ether are perfectly aseptic, as they are made in facto- ries where they must be handled by many indi- viduals. It can scarcely be expected that these working-people have full knowledge of their great responsibility. The germicidal power of chemical substances will often be impaired if they form combinations with the substances they encounter, which com- binations may sometimes account for the unto- ward results of disinfection. For instance, neither faeces nor sputa can be disinfected with bichloride or other antiseptic solutions. The disinfecting power of corrosive sublimate upon pus and blood is very small, and when used upon such albumi- noids it can be intensified only if tartaric acid be added. An antiseptic agent w^hich may be power- ful in a watery fluid containing spores of the bacil- lus anthracis may be useless in alkaline and acid fluids or in albuminous mixtures. Another ofreat 68 SURGICAL ASEPSIS. difficulty in disinfection lies in the fact that the disinfectant may not directly reach the seat of the microbes. There is a orreat difference between disinfect- ing an instrument contaminated by infectious material and disinfectinor a nest of bacteria im- bedded in filth and similar substances or in necrotic tissue. Eight years ago, the writer ' emphasized the fact that the bacilli of diphtheria cannot be destroyed as long as they multiply beneath the membrane, from which all antiseptic substances rebound. A local rational treatment can be carried out only if the antiseptic sub- stances penetrate the necrotic tissue — that is, if the membrane is removed first, so that the mi- crobes that have settled in the sub-membranous tissue can directly be attacked. The writer has several times, and with appar- ent success, tried to remove the diphtheritic membranes with the sharp curette, afterward ap- plying a bichloride spray (i : looo) every fifteen minutes during the first twenty-four hours. In performing tracheotomy in a family where four children suffered from diphtheria at the same time, the writer happened to notice an extensive diphtheritic membrane on the labia majora of the baby. After having curetted the membranes and dressed the affected surface, die temperature in 1 I\Jnv Yorker medic inisc he Presse. MEANS OF DISINFECTION. 69 seven hours fell from 104° to 99°. The swelling of the neighboring glands also subsided promptly. The effect was so obvious that the same proced- ure was tried on the tonsils. The apparent cruelty of this treatment, the irritation of the healthy mu- cous membrane, and the difficultyof employing the treatment as soon as the naso-pharyngeal vault has been reached by the diphtheritic process, naturally prevented its adoption in its present shape by the profession. The use of the galvano-cautery, which was advised later on, experienced the same fate. A. Seibert, acting upon the same premises, devised an ingenious method of penetrating the membranes, so as to attack the microbes beneath, by using a syringe for the sub-membranous local treatment of diphtheria. The point of the syringe consists in a series of small hollow needles (like those of a hypodermic syringe), of sufficient length to penetrate the membrane, through which an antiseptic fluid can be brought Into contact wdth the sub-membranous tissues. The weak point of this method is that the fluid comes into contact with the membrane only at that point at which the needle Is Inserted, so that merely a limited area of the tissues can be Impregnated with the disinfectant. So lone as surgeons are unfamiliar with any other than local germicidal methods, especially with a method of inoculation which will disinfect the system, a rational mode JO SURGICAL ASEPSIS. of treatment can be reached only on the basis of the principles explained on page 68. There is no doubt that protection as well as a kind of disinfection of the body — that is, artificial immunity against a series of infectious diseases — can be obtained, as shown in Section I., in various species of animals, toward the influence of dif- ferent microbes. Some animals do not show any reaction at all toward certain species of microbes that are highly virulent to other animals ; in other words, they are immune against them. For in- stance, rats and dogs are immune against the bacillus anthracis ; men are immune against the cholera of chickens, erysipelas of pigs, etc. Such natural immunity is probably caused by the dif- ferent chemical composition of the blood. As is well known, infectious diseases like measles, scar- let fever, and small-pox attack an individual only once, because the system, after having stood the disease once, becomes immune against a relapse of a disease of the same kind. Such immunity is called "acquired," in contradistinction to the one called "artificial," which has long been known. Indians and Chinese several thousand years ago rendered themselves immune against infection during epidemics of small-pox by in- oculating themselves with the small-pox virus. They did it by scratching the skin-surface. They produced a slight infection with small-pox, MEANS OF DISINFECTION. 7 1 which infection protected them from acquiring the disease in its greater or original virulence ; that is, they became artificially immune for a certain leno-th of time ao^ainst variola. The immortal merit of Jenner is that he utilized these facts methodically. In accord with the observations made after vaccinations with cow's lymph are the numerous experiments of Pasteur, Koch, Loeffler, Klebs, Chauveau, Roux, Wooldridge, Kitasato, Behring, Wernicke, and others, who tried to ob- tain artificial immunity of the system against cer- tain infections by inoculations with the weakened virus of microbes. There can be no doubt that mitigated cultures of microbes are apt to prevent, or at least to diminish, the toxic effects of virulent microbes of the same kind under certain condi- tions. These facts Metschnikoff tried to explain by his theory of the phagocytes (compare Sec- tion I.), founded on the presence of substances called " phagocytes " which are hostile to the microbes. The white blood-corpuscles especially are supposed to possess this peculiarity, as they are of the same derivation as the mesoderma, and therefore have also a decided digesting power, which enables them to destroy microbes entering into the circulation. If these elements are not powerful enough to prevent the entrance of the microbes, the latter multiply In the individual and cause disease or death. When, by means of pure 7-2 SURGICAL ASEPSIS. cultures, Metschnlkoff had inoculated guinea-pigs susceptible of infection with the bacillus anthra- cis, he found that the phagocytes would not destroy the microbes, while in non-susceptible animals of the same species destruction took place ; when mitigated cultures were used, the phagocytes showed enough power to destroy the microbes, which had then lost a great deal of their virulence. By inoculating such animals repeatedly with mitigated cultures Metschnlkoff at last succeeded in makincr them resistant to the most virulent cultures. That the white blood-corpuscles really possess the power to destroy living microbes has been doubted ; it seems to be more probable that they clean the tissues from dead organic particles by enveloping them. Pasteur and Klebs advance the theory that after the first inoculation with mitigated cultures the (greater amount of the substances which represent the soil of the microbes is consumed and not reproduced, so that cultures inoculated later on do not find an amount of favorable soil sufficient for their development and multiplica- tion. Similar hypotheses were advanced by Chau- veau, Salomon, Smith, and others. As Buchner claims, the albuminous substances of the body exert bactericidal power, and he therefore advised the inoculation of susceptible MEANS OF DISINFECTION. 73 animals with the blood-serum of animals possess- ing natural immunity. The blood-serum of ani- mals rendered artificially Immune was finally utilized to produce Immunity in other animals. Thus, Behring and Kitasato succeeded In pro- ducing Immunity against tetanus in a manner similar to that by which vaccination Immunity Is obtained against small-pox. Recently, Behring, Wernicke, and Ehrlich discovered that the bac- tericidal capacities of the serum of animals ren- dered Immune in the above-described manner can be utilized for sanative purposes. The cura- tive power of the serum of Immunized animals is supposed to depend upon its antitoxic influence upon the organism of the affected individual. Good results from this new therapy are re- reported In tetanus and typhus. The splendid results claimed by Behring, Wernicke, and Roux in the treatment of diphtheria are universally known and deserve the greatest attention. The effect and quality of the serum depend upon the degree of Immunity which the Immunized animal has reached, and which can be determined by the frequency with which the Immune animal, without belne killed, can be inoculated with the minimal dose of the virus deadly for normal animals. To what extent the antao^onism of some mi- crobes can be utilized future experiments have 74 SURGICAL ASEPSIS. yet to show. For instance, the bacilhis fluores- cens putidus is a decided antagonist of the pus cocci and of the bacihi of pneumonia and of ty- phus ; this is evidenced by the fact that if cultures of the bacillus fluorescens putidus are produced on gelatin, they will be non-susceptible for the implantation of the other microbes mentioned. Emmerich was able to save the lives of rabbits poisoned with anthrax bacilli by inoculating them with the cocci erysipelatis or with the bacillus prodigiosus or pyocyaneus. Fehleisen, by inoc- ulating patients suffering from malignant tumors, especially from sarcoma, with the streptococcus erysipelatis, has repeatedly effected cures. The results obtained by Bull and Coley corroborate the importance of this discovery. If thus bacteria are destroyers of bacteria, we should not give up hope of finding proper means of destroying septic microbes by inoculation also. Injections with the toxines of diphtheria have been tried by the writer in a case of septiceemia, with apparent success. Toxine prepared by the writer from the blood-serum of septic animals also showed some effect in a case of septicaemia. The discovery of practicable methods of carry- ing out the principles of general disinfection would certainly be well worthy of indefatigable investigation. It should, however, not be lost sight of that the effects in a test-tube are dif- MEANS OF DISINFECTION. 75 ferent from those obtained in the Hvinor orgran- ism. Another point which renders disinfection by chemical substances impossible is the fact that some disinfectants prevent their own penetration by forming an impermeable stratum around the object of disinfection — such, for instance, as pro- duce a layer of coagulated albumin around balls of sputa. Chemical disinfectants contend with similar difficulties as regards oily or fatty substances. Oil prevents all antiseptic agents, even bichloride, from penetrating tissues. It mat- ters not if the disinfectants are dissolved or sus- pended in oil or are dissolved in water, or if the microbes are suspended in oil or in fat. The microbes are well protected by the layer of fat enveloping them, and there is no chemical sub- stance strong enough to destroy the microbes by permeating this layer. Other experiments (Schimmelbusch) have un- dermined confidence in the power of chemical disinfectants. There will be mentioned only the inoculation (anthrax) with septic substances of the distal end of a mouse's tail. No matter what the kind and the strength of the disinfecting agent used to disinfect immediately after inocula- tion, mice so treated died of sepsis, except when the tail was amputated within at most five min- utes after infection. Richter found the bacillus 76 SURGICAL ASEPSIS. anthracis In the lungs, kidneys, liver, and spleen half an hour after such an inoculation. It must, however, be borne In mind that these experiments do not, as a rule, correspond entirely to the -conditions found in surgical practice, be- cause they were made with pure cultures of highly virulent microbes. As noted in Section I., on the Influence of Microbes, the difference In the poisonous effects of the various microbes consists In their power of resistance against the tissues of the human body. Some of these micro- organisms multiply only In the juices of the body; others multiply only after having destroyed their soil or after having found a point of diminished resistance — for instance, a solution of continuity. Despite the great number of disappointing results of such tests, carbolic acid and bichloride of mercury are still most en vogue as disin- fectants. Carbolic acid (phenol), derived from coal-tar, has been known since 1834. No attention was paid to It until Joseph Lister made his revolu- tionizing experiments after studying Its disinfect- ing Influence upon sewage. For years, notwith- standing its great disadvantages, it occupied the front rank as an antiseptic before, during, and after all operative procedures. Koch's researches showed that weak solutions of carbolic acid are incapable of destroying such MEANS OF DISINFECTION. 77 microbes as are of importance to the surgeon, and that even strono- solutions were uncertain in their effects and required a comparatively long time to act. In full strength carbolic acid could not be used in those operations in which it would have been most desirable, such as laparotomy, etc. On account of the irritating effects of the drug, it could not be borne by so delicate a membrane as the peritoneum. Doubtless hundreds of patients, especially children and anaemic and cachectic indi- viduals, have succumbed to the poisonous effects of this druof. Accidents are often due to the careless use of carbolic acid by the public at large. Within the past year the writer was obliged to perform no less than seven amputations for gangrene of one or more fingers caused by carbolic acid. The patients, generally suffering from a trifling injury and knowinof carbolic acid to be " a orood wound <_> o medicament," buy a few cents' worth of the pure drug at the drug-store, where purchasers often are insufficiently informed as to its dilution. They add some water to it without mixing it well by sdrring, and some of the injured parts come in contact with the pure carbolic acid; or they mix it well, but use too strong a solution. Con- sequently the tissues, as their fluid is taken out from them, shrink as they do in a burn of the third degree ; the circulation becomes impeded, 78 SURGICAL ASEPSIS. and gangrene is the consequence. As local anaesthesia is caused by this process, the patient, unfortunately, feels relieved, and continues this treatment until the gray or black appearance of the finorer calls attention to the oreat dano;er to which he has exposed himself. The writer has repeatedly seen and heard of similar accidents in gynecological practice, where the patient, instead of first mixing the carbolic acid in a pitcher or a basin, put the acid directly into her fountain syringe, added some water, and stirred it. The weight of the acid caused it to settle into the tube in its pure state, while the water in the bag contained only a trifling quantity of the acid ; hence, naturally, when the patient introduced the nozzle of the irrigator into the vagina, the drug in its full strength came in contact with the mucous membrane and produced most extensive and danorerous destruction. The free sale of this drug should be prohibited by law. It is evident that Lister himself was well aware of these dis- advantages, for he called carbolic acid ** a neces- sary evil," which could not be dispensed with so long as nothing superior was presented. Bichloride of mercury (hydrargyrum bichlora- tum corrosivum, corrosive sublimate) has been known for many centuries. Its use internally was recommended by Paracelsus. After Robert Koch and Theodor Billroth demonstrated its bac- MEANS OF DISINFECTION. 79 tericldal superiority over carbolic acid it was soon unanimously adopted by the profession, especially in consequence of the efforts of Bergmann, Schede, and others. Although it is at least as poisonous as carbolic acid, no surgeon would now care to do without it. But in connection with asep- tic wounds it should almost exclusively be used to disinfect the field of operation and the hands of the surgeon. It cannot be employed for disinfect- inginstruments, on accountof its destructive action upon metal. As a solution it should be used in combination with distilled water only ; if ordinary water is used, the earthy substances (carbonic alka- lies) of the water combine with the mercury, form- ing an insoluble combination (bi-, tri-, or tetra-oxy- chloride). To prevent this the addition of acids has been suggested. Fiirbringer recommended salicylic, acetic, or hydrochloric acid ; Laplace, tartaric acid ; and Von Bergmann, chloride of so- dium. As shown by Fiirbringer, the influence of light and air is apt to impair the stability of a bichloride solution. A convenient stock solution, preferably 5 per cent., can be made by dissolving equal parts of corrosive sublimate and common kitchen salt in hot distilled water. Its influence upon wounds covered with pus or with blood is insignificant ; hence, to obtain satisfactory results, the previous removal of such substances is es- sential. 80 SURGICAL ASEPSIS. Although the writer has used bichloride very extensively, under proper precautions, for a num- ber of years, he has seldom met with alarming symptoms attributable to the use of mercury in infected wounds. Eczema and salivation and in- flammation of the gums were repeatedly observed, but these symptoms disappeared promptly after the druor was discontinued. The writer has re- peatedly employed a 0.05 per cent, solution to wash off fibrinous exudations of the intestine in peritonitis or in gangrenous herniae, without hav- ing perceived any symptoms that could be traced to its use. It is of the greatest importance, of course, to protect the abdominal cavity with ster- ilized compresses, so as to apply the solution only to that part of the intestine lying outside of the cavity, and immediately thereafter to wash it off with sterilized w^ater. Chloride of zmc\\2.s been recommended by Bill- roth, Von Bardeleben, and especially by Kocher, the last named claiminof that even so weak a solu- tion as 2 : 1000 exercises a decided and all-suffi- cient antiseptic influence. This claim, however, has not been corroborated by other surgeons. The value of the chloride of zinc (a watery solu- tion of 8 per cent, being preferable) seems to rest mainly upon its strong cauterizing qualities. Its good effect upon torpid ulcerations, fistulous tracts, etc. is unquestionable. The writer uses MEANS OF DISINFECTION. 8 1 it preferably on those ulcers for which nitrate of silver is ordinarily recommended, as the chloride exercises antiseptic as well as cauterizing effects. Salicylic acid is made synthetically from car- bolic acid, over which it possesses the great ad- vantage of being much less poisonous. Only when in powder form and when placed upon wounds in large quantities has it really shown poisonous effects ; but this advantage is some- what counterbalanced by its weak antiseptic power, which can be increased by the addition of boric acid. The following is a desirable for- mula for that purpose : Salicylic acid, I part; Boric acid, 6 parts ; Water, 500 parts. Where large wound-surfaces are involved, as In the case of burns or scalds, the writer found the salicylated gauze very useful (p. 124). Aluminum aceticum, consisting of sugar of lead 25 parts, alum 5 parts, and water 500 parts, is used by Maas and Fischer for irrigation and as a moist dressing. It is prepared by slowly addine the suear of lead to the cold solution of alum. It has also been particularly recommended whenever there are special reasons for appre- hending poisonous effects from the use of car- bolic acid or of bichloride of mercury. 6 S2 SURGICAL ASEPSIS. Peroxide of hydrogeji has recently been used extensively, and apparently with good results. Its precise value still remains to be determined, as the solutions generally used are not absolutely germicidal — a fact which can be proved by the experiments of Kyle, who found the tetanus bacillus growing in a 15-volume solution. Its main advantage lies in its power of destroying albuminoid elements, upon which the microbes multiply. Unlike bichloride, which is rendered powerless by albuminoid elements, hydrogen per- oxide is especially useful in suppurative pro- cesses. Pyrozone (aqua hydrogenii dioxidi), containing 3 per cent. H2O2 in permanent solution, possesses the same qualities as does the peroxide, but ap- parently to a somewhat higher degree. Of the vast series of antiseptics recommended during the last decade, there may be mentioned thymol, natrium, borax, naphthalin, benzoic acid, zincum sulpho-carbolicum, terebene, eucalyptol, tinct. iodi, china, chloral, chloroform-water, per- manganate of potassium, camphor, glycerin, citric acid, tar-water impregnated with oxygen, sul- phuric acid, picric acid, resorcin, balsam of Peru, styrone, charcoal, powdered coffee, naphtho],asep- tol, salicylresorcin, ketone, chromic acid, tannic acid, trichloride of iodine, creolin, pyoktanin, lysol, ichthyol, thiol, alumnol, turmerol, solveol, MEANS OF DISINFECTION. 83 iodol, salol, europhen, aristol, sulphamlnol, sozo- iodol (hydrargyrum sozoiodolicumj, euphorin, for- malin, and, last but not least, iodoform. Experi- ments made by the writer at the New York Ger- man Poliklinik with acetanilide, phenacetine, and phenocoll proved that these drugs also possess antiseptic qualities.' The limits of this volume preclude giving the characteristics of all these antiseptic substances. The selection of any one of them seems frequently merely a matter of choice. Iodoform is the ideal antiseptic drug ; despite all that may be said against it, it must be con- ceded that no equivalent for iodoform has yet been found. It is easily dissolved in alcohol, in ether, in chloroform, and in oils. According to G. F. C. Mijller,^ iodoform remains in an unde- composed state dissolved in all decoctions — w^ith glycerin, in water and watery fluids, and in mix- tures of the same kind if they are exposed to the heat of a sterilizing apparatus. Naturally, it remains suspended also in such mixtures if it is exposed to the temperature of the body. Iodo- form incorporated in the system for the most part remains unchanged ; this can easily be demonstrated in the urine of patients. * " The Antiseptic Value of Phenocoll Hydrochlorate," N. V. Medical Jourjial, March 19, 1893. ^ Aerztlichcr Praktiker, February 22, 1S94. 84 SURGICAL ASEPSIS. No drug has ever been praised so highly and condemned so fiercely as iodoform. While hardly any surgeon was unconvinced of its antiseptic value, Kronacher, Fleyn, Rovsing, B. Tilanus, and others demonstrated that streptococci as v^ell as staphylococci can easily be cultivated in iodoform powder. This led to the deduction that iodo- form has no antiseptic qualities. But their con- clusion manifestly admits of modification. Their experiments demonstrated only that iodoform has no direct influence upon microbes. De Ruyter and Behring showed that iodoform renders products like the ptomaines (toxines) of certain microbes harmless by forming innocuous combinations with them ; furthermore, a decom- position of iodoform by the microbes takes place, during which decomposition a bactericidal effect is exerted. Probably nascent iodine is set free during this process. The more advanced is the putrefaction, the more intense is the bacterici- dal action of iodoform ; hence, although it has no active disinfecting power like that of bichlo- ride of mercury, it is one of our most valuable medicaments, particularly as, besides its indirect disinfecting quality, it has the power of reducing secretion and of mitigating pain, and, in addition, exerts a decided antitubercular influence. (Com- pare Section XL, on Open-wound Treatment, and Section XIV., on Aseptic Injection.) MEANS OF DISINFECTION. 8$ The writer recently used iodoform for other than antiseptic purposes. Having frequently noticed the excellent influence of an ethereal solution of iodoform upon cysts, lymphomata, goitre, etc., he used it successfully in hemor- rhoids, varicocele, hydrocele, and varicose veins.' The splendid results obtained with the iodoform treatment after resection of tubercular joints and after extirpation of tubercular glands induced the writer repeatedly to use comparatively large quantities of iodoform in tubercular peritonitis. The striking manner in which the powder, as also the mixture, was borne by the patients led to the idea of using it also in general peritonitis. The injection of one ounce of a lo per cent, mixture of iodoform and glycerin has repeatedly been made in general peritonitis, as also in cases where infectious pus escaped into the abdominal cavity during operation.^ The writer does not claim any specific results for this treatment, which would be useless in acute septic peritonitis, but it is noteworthy that of five cases of suppurative peritonitis so treated, in which the chances of recovery were very poor, four terminated favor- ably. It cannot be proved, but it is conceivable, that the virulence of the pus — that is, the influ- ^ *' The Value of an Ethereal Solution of Iodoform in the treatment of Hemorrhoids," N. V. Medical Joia-nal, July 21, 1894. 2 " Tubercular and Suppurative Peritonitis," N. Y. Medical Journal, April 21, 1894. S6 SURGICAL ASEPSIS. ence of the toxines — may be weakened by the co-absorption of the iodoform (see p. 255). Whenever abundant discharges into the ab- dominal cavity may be expected, the writer usu- ally dusts the site of operation with powdered iodoform ; ordinarily it should be used only in connection with gauze, thus materially diminish- ing the danger of poisoning. But, although the writer has used iodoform most extensively dur- ing sixteen years, he never saw any serious symptoms traceable to its employment that did not promptly subside after its discontinuance. Some individuals have for iodoform a peculiar constitutional susceptibility, a real iodoform- idiosyncrasy, which manifests itself either in the appearance of papular or urticarial eruptions on the skin or in symptoms of brain- or heart-de- rangement, the latter generally by a frequent, small, irregular pulse. Besides these symptoms, disturbances of digestion and of the nervous sys- tem — headache, depression, debility, and sleep- lessness — may occur. Anaemic or cachectic patients and aged individuals or infants, particu- larly if they suffer from heart or kidney diseases, should carefully be watched when iodoform is used on them, so that the symptoms of intoxica- tion may be recognized at their earliest stage and readily be overcome. Undoubtedly, many cases of supposed iodoform-poisoning were really MEANS OF DISINFECTION. 8/ septicsemic, some of those who reported such cases not being sufficiently famiUar with the vari- able features of septicaemia — for instance, lacking the knowledge that the low temperature was sometimes characteristic of its most deleterious type. If used in large crystals, the local effect of iodoform is more intense and endurino- and because of its slow decomposition the drug is less apt to be absorbed ; it displays its main advantage, however, in the shape of iodoform gauze, the preparation of which will be shown in Section V., and its value and use in Section XI. ^ — — ^= ^ Fig. 20. — Beck's bladder-pistol. Iodoform may be used in connection with col- lodion as a protection for wounds in which no secretion is expected. Its value as a suppository in connection with cacao-butter renders it useful in fistulous tracts and in hollow orcrans like the rectum and bladder. For the easy introduction of such suppositories or pencils the writer has de- vised his porte-remede (bladder-pistol; Fig. 20).^ The offensive smell of iodoform cannot be ^ " Ueber intravesicale Behandlung, etc.," N'ew Yorker medicitiische Wochenschriftf March 3, 1889. 88 SURGICAL ASEPSIS. neutralized except by impairing its value. Tonka and coffee beans, which were highly recom- mended as deodorizers of iodoform, prove in- efficient. If personal objection to the odor of iodoform prohibits its use, aristol and the non- poisonous dermatol are the most available sub- stitutes. It would be of great help, in determining whether any or what kind of disinfection should be selected, if bacteriology was sufficiently ad- vanced to furnish information, during an opera- tion, of the character of the infecdng elements. The sureeon would then know better how to combat them. In some cases, however — for in- stance, in suppurative processes in the abdomi- nal cavities, where specimens could not be ob- tained before operation — the writer has tried repeatedly during operadon to get some infor- mation by the microscope as to the nature of the microbes.^ Especially was a differendadon be- tween gonococci, streptococci, and staphylococci desired. Bacteriological investigations — that is, making cultures — are of course out of the ques- tion during an operation ; furthermore, the cha- racterisdcs of microscopical slides of the microbes in general are not always so distinct that a posi- tive differendation by the microscope alone could ' Comp, Transactions of Ihe Eleventh International Medical Coni^ress, Rome, March 30, 1894. " On Tubercular and Siipimralive Peritonitis." MEANS OF DISINFECTION. 89 always be made. But In reference to the most frequent abdominal operations — that Is, to those indicated by suppurative Inflammatory processes of the adnexa — valuable Information can be gained by simple knowledge of the fact that, with very few exceptions, either streptococci, staphyl- ococci, or gonococci are the originators of such inflammations. Other microbes need scarcely be considered, as the bacteriological investigations of Schauta, Werthheim, Menge, Prochovnick, and others have proved. The morphological features of the three cocci mentioned above, for- tunately, are, unlike those of many other species, so well marked that they can almost always be differentiated by a microscopical examination alone. For instance, the other pyogenic cocci can easily be distinguished from the gonococci bypass- ing a cover-glass preparation through the flame of an alcohol lamp and staining it by the method of Gram; while characteristics of the gonococcus are its peculiar shape. Its size, and its being found within the cells. Another valuable point of dif- ferentiation is that as soon as gonococci are found the presence of streptococci or staphylococci can almost always be excluded. Such an exami- nation, which, If everything has been prepared before operation, does not require more than a few minutes, would contribute to a decision of the question of disinfection. If the pus was 90 SURGICAL ASEPSIS. found to be either sterile or to contain gonococci, the abdomen could be closed and union by first intention would be obtained, while if cocci of greater virulence, such as streptococci or staphyl- ococci — in a word, such cocci as are not gono- cocci — are found, disinfection and drainage should be employed. (Compare Section XL, on Open- wound Treatment.) In cases like pyothorax or similar accumulations of pus, where aspiration of the pus can easily be done before operation, such investigation can be carried out by microscope and culture mediums. The o^reat value of such bacterioloofi- cal examination in diagnosis and prognosis is undoubted. In pyothorax, for instance, the presence of streptococci would point to the presence of solid masses, while pneumococci or staphylococci would indicate liquid pus. But such examinations do not yet possess such a de- gree of perfection as to be an infallible guide for the character of an operation for pyothorax.^ Manifestly, notwithstanding the great progress of the last few years, the methods of disinfection are still far from being perfect, and the main dependence is in prophylactic measures. Bac- terioloo-ical researches have demonstrated that disinfection is not identical with the simple use of a so-called "antiseptic" agent, but that it re- ^ "Pyothorax and ils Treatment, ' N. Y. Medical Record, May 19, 1894. PROPHYLACTIC DISINFECTION. 9 1 quires a thorough knowledge of an entire series of fixed principles. The mastering of disinfection does not simply mean knowing the strength of an antiseptic fluid, but consists in knowing also the condition of the object to be disinfected, and the vitality of the microbes established in this object. Furthermore, there must be considered all the difficulties of disinfection resulting from dirty, oily, or fatty substances surrounding the object to be disinfected, and those that result from chemical decomposition. The length of time required to disinfect an object is likewise of the greatest practical im- portance. There is no advantage in knowing methods by which a microbe can be destroyed by keeping It in carbolic acid for three weeks. In practice this knowledge is of no value, for the surgeon cannot wait ; he requires his armamen- tarium disinfected within a very few minutes. IV. PROPHYLACTIC DISINFECTION. The old proverb which says that " an ounce of prevention is worth a pound of cure " might well serve as the motto of asepsis. Prophylactic asepsis — there Is no other fitting adjective — rests mainly upon the disinfection of the surgeon's hands, of the Instruments, and of the field of oper- ation. As shown In Section I., the number of 92 SURGICAL ASEPSIS. micro-organisms on the outer surface of the body is legion, while within the tissues no microbes are found ; therefore their removal from the sur- face of the body must be effected befo7^e proceed- ing to any surgical operation. The Jiands and forearms of the surgeon are best cleansed accordinof to Fiirbrinorer's and Kiimmel's methods, which depend more upon mechanical thoroughness than upon the choice of any special antiseptic. The skin must be brushed energeti- cally w^ith very warm water and green soap for three to five minutes, and then be dried with a sterilized towel. Scrupulous cleansing of the fin- ger-nails with a small metal nail-cleaner is of the greatest importance. Not less than one minute, preferably longer, should be devoted to the nails. The writer has used Braatz's nail-cleaner (Fig. 21) with great satisfaction for several years. The Fig. 21. — Braatz's nail-cleaner. surgeon should have his nails cut short and rounded. Nail-files must be avoided, as they form irregular surfaces from which the microbes cannot so easily be removed as from a sharp cut done with scissors. The wearing of rings during an operation shows a misconception of PROPHYLACTIC DISINFECTION. 93 the principles of asepsis. Even if the rings be exceptionally clean, the little folds of the skin be- neath them can shelter micro-ororanisms. After cleanings the fingrer-nails the skin must be rubbed for about one minute with a sterilized-orauze tam- pon dipped in pure alcohol (80 per cent.). This procedure is followed by washing and rubbing with a bichloride solution (i : 1000) for another minute. If contamination with especially infectious mate- rial shortly before the operation was inevitable, the whole procedure recited above must be re- peated. The entire process of disinfection should consume from five to ten minutes. Howard A. Kelly^ recommends washing the hands and the forearms with common brown kitchen soap for ten minutes, and then covering them with a hot saturated solution of permanga- nate of potash until they are stained a deep ma- hogany-red. After this treatment he advises that the hands be immersed and be moved about in a hot saturated solution of oxalic acid until all the permanganate is removed ; they should then be dipped in milk of lime or in plain water to wash off the oxalic acid. There can be no doubt as to the efficacy of both these methods, and the choice is simply a matter of taste. Disinfection does not depend upon one or another antiseptic, but is an art/^r ^ American Text- Book of Gynecology^ Philada., 1894. 94 SURGICAL ASEPSIS. se, and must be learned as such. A well-trained surgeon will clean his hands more effectively in one minute by brushing than a less experienced surgeon will do by using the whole armamenta- riiuji ascpticiun for hours. It is self-evident that after the hands have been washed the surgeon should not touch anything except aseptic articles, lest he reinfect himself before operation. If, however, non-aseptic objects have to be grasped, it is, to save the time for redisinfection, sometimes advisable to put on long sterilized gloves consist- ing of linen or of rubber dam. With the aid of such aseptic gloves all manipulations about the patient that are apt to be a source of infection can safely be done without the risk of contami- nation later on. As soon as the necessary prep- arations are finished, the gloves may be taken off and the hands be washed only in the bichlo- ride solution. It would be wrong, for instance, if, after having brushed the hands, the cork of the bottle con- taining the alcohol, or later on the vessel filled with bichloride, was grasped without having gloves on or without having those objects sur- rounded by sterilized gauze. To avoid this con- tact entirely the alcohol and the bichloride would better be kept ready for the surgeon separately in basins. Braatz, assuming that in the cleansing process PROPHYLACTIC DISINFECTION. 95 the water required frequently to be changed, dur- ing which process the surgeon might be tempted to turn the spigot on or off with his hands, where- by contamination could easily take place, devised a pedal attachment for the spigot, such as is cus- tomary in many houses of the better class in Russia. A horizontal bar is substituted for the handle of the ordinary hydrant spigot, or the stop-cock of an irrigator is attached to a chain reaching down to near the floor, where a lever is attached to it. This lever acts as a pedal, pres- sure upon and release of which serve respec- tively to turn on and to cut off the water-supply. There is no doubt that such an attachment adds greatly to the comfort of the surgeon In a hos- pital ; its absolute necessity, however, is open to discussion. The skin of the patient must first of all be cleansed by one or several warm baths before operation. When virulent contamination has taken place, or If unclean individuals are handled, the skin, especially over the site of operation, should be scrubbed with ether after the second or third bath. Before undertaking operations upon parts such as the feet, which, as a rule, are not washed reg- ularly by most individuals, the thickened epider- mis cannot be rendered sterile by following the principles of prophylactic disinfection for one 96 SURGICAL ASEPSIS. time only. There are legions of saprophytes and pathogenic microbes sheltered by such skin- surfaces, and a mere temporary influence of moisture is apt to cause them to develop and to multiply. Such parts must be prepared in the most radical manner. For at least three succes- sive days there must be given a bath, which is to be followed immediately by a thorough scrubbing with a bichloride solution (1:500). The parts are then surrounded by a compress of aluminum acetate covered with oil silk. This application must remain in situ until the following day, when the bathing, scrubbing, etc. must be repeated. If these procedures are carried out for three days, the hypertrophied epidermis will become macer- ated and may easily be wiped off. It is often advisable in preparing a patient for an operation, such as laparotomy, to cover the field of operation with a poultice of green soap on the evening preceding the day of operation, after prophylactic disinfection has been carried out. After the soap has remained for three hours it is scrubbed away, thus removing as much epithelium as possible. A towel saturated with a bichloride solution is then applied, and is allowed to remain until shortly before the operation. The field of operation and its vicinity must invariably be shaved if there is the slightest evi- dence of the presence of hairs ; the region must PROPHYLACTIC DISINFECTION. 97 next be scrubbed with soap and hot water, and afterward with alcohol and bichloride-of-mercury solution. All operations in the vicinity of the umbilicus, especially laparotomy, require particular atten- tion to thorough disinfection of the part. This disinfection is extremely difficult, and is some- times even impossible. The folds of the umbil- icus must be exposed as far as possible, and mechanical cleanliness must be observed to the utmost extent. Whenever the exposure of the folds of the umbilicus is difficult, the writer has found it useful to pour a teaspoonful of a satu- rated solution of iodoform-ether or of sterile iodoform-collodion into its grooves, thus cover- inof and closino- the dangerous folds. Mucous membranes cannot be disinfected as thoroughly as the skin. Antiseptic solutions are not borne well, and they even irritate the mucous membranes, the absorbent power of which tends to intoxication, as clinical experience has repeat- edly shown ; furthermore, the effects of bacter- icides upon mucous surfaces, if not exerted per- manently, are questionable. Steffeck found that irrio^atine the vao-ina with a 0.1 per cent, solution of bichloride does not exercise the slightest destroying influence upon the micro-organisms of this organ ; hence me- chanical cleansinor must be resorted to as the most o 7 98 SURGICAL ASEPSIS. effective agent to the desired end. If an opera- tion in the vagina is to be ])erformed, the exter- nal crenitaha must be cleansed in the manner described on page 95, and the hairs must be shaved. Then the vagina itself must be cleansed thoroughly with green soap and hot water. The whole organ must be wiped out energetically with a piece of gauze dipped in green soap, and afterward be wiped with gauze saturated in ether. Whether or not sterilization of the vaccina and the uterine cavity by a steam-atomizer (like that of Von Farkas, p. 108), as recently recom- mended, can practically be carried out has still to be proved. The writer always found it useful to apply an ethereal solution of iodoform with a spray, as, in case the microbes have not thor- oughly been destroyed, this solution will so cover the infectious area that the microbes will not come in direct contact with the wound to be made. The same procedures may be undertaken in other hollow organs. No one claims to possess a safe means of rendering strictly aseptic the rectum or a bladder containing stones bathed in purulent urine ; yet practically a great deal may be done in this direction. In operations on the rectum it is self- evident that laxatives should freely be given and enemas also be administered. Tampons consisting of sterilized gauze, and PROPHYLACTIC DISINFECTION. 99 connected with a thread to make their subsequent extraction easy, should be introduced above the field of operation, to guard it against contamina- tion by feces during the operation. Medicaments, such as calomel, salol, etc., which would disinfect the contents of the intestine have repeatedly been recommended, but their efficacy remains still to be proved. Thorough disinfection of the bladder is very difficult, and is often impossible. In a healthy bladder containing healthy urine no microbes are ever found, while in diseases of the bladder they are only exceptionally absent. Cazeneuve and Livon imitated retention of urine by con- stricting the pendulous portion of the urethra; after ligating the ureters they extirpated the bladder, extended by the accumulated urine, and preserved it in an incubator for a considerable length of time ; nevertheless, decomposition, shown by the presence of micro-organisms in the exsected bladder, was observed. The manner in which microbes enter the blad- der is unknown. It remains to be proved that they can be brought from the kidneys. Undoubt- edly, in the great majority of cases they are car- ried into the bladder by instruments used in surgical operations. Therefore none but per- fectly aseptic catheters, sounds, etc. should ever be used. The special niodits operajidi of disinfect- lOO SURGICAL ASEPSIS. ing such instruments will be shown in Section V., in which their steriHzation is described. A cfreat impediment to the fulfilment of all the premises of asepsis is the ttrethra, which must be passed before the bladder can be reached. As Manna- bero^, Rovsinor, and Lustg^arten have shown, the healthy urethra always harbors whole series of micro-oro-anisms. Therefore it does not suffice to use sterilized instruments, but the urethra must also be cleansed before such instruments are passed. This cleansing of the urethra is very difficult, and uncertain as well. But it is the duty of the physician to employ his best endeavors, and he certainly can do a great deal by observing the followdnof rules before introducincr a catheter : (i) Clean the orifice thoroughly, after the princi- ples expressed on page 95 ; (2) irrigate the urethra by the recurrent stream of an irrigating catheter. Boric-acid, Thiersch's or bichloride (i : 25,000) solution, best answers the latter purpose. Before operations on the bladder or urethra are undertaken, irrigations with bichloride (i : 25- 000) should be employed every ^\^ hours for several days, if possible. The urine may be dis- infected to some extent by administering one or two drachms of salol within twenty four hours of the operation. The same preliminary arrange- ments are required for operations on the kidneys. PROPHYLACTIC DISINFECTION. 10 1 Before operations on the stomach are under- taken, repeated irrigations of that organ are re- quired. Operations on the mouth require, first of all, mechanical disinfection — that is, the scrubbing of the teeth, etc. with sterilized gauze. It will often be necessary to use a nail-cleaner to scrape the teeth, and to brush them afterward with a tooth-pow^der such as the following : Pulv. oss. sepiae, 70 parts ; Pulv. rad. iridis Florent., 20 parts; Bicarb, sodae, 10 parts. Then a solution of permanganate of potassium or of boric acid should freely be applied as a wash. The above- indicated procedures should be carried out, if possible, during several days ; that is, the mechan- ical disinfection should be repeated at least twice a day, and the washing of the mouth every hour. The nose requires little attention, as microbes are found in it only exceptionally. This fact ex- plains the rare occurrence of sepsis even after the most careless operations upon this organ. At any rate, it should be cleaned repeatedly before operation with a i per cent, boric-acid solution. Thorough cleansing of any part of the body implies the need of a good soap. In the writer's opinion, green soap (sapo viridis) is the very best for the purpose. There are some kinds of soap in the market, so made by careless manufacturers that the animal fat, impregnated with numberless 102 SURGICAL ASEPSIS. micro-organisms, has not been saponified by the appHcation of heat. Thus, of course, infection with such a " disinfectant" would be possible. The implements with which disinfection of the body or of any of its parts is secured deserve somewhat detailed attention here. The most important of these implements is the brush, which deserves much closer consideration than is usually given to it. Many surgeons who otherwise may be quite scrupulous do not hesitate to use, shortly before opening an abdomen, brushes that have lain in the dirtiest corner of the room. Some surgeons who appreciate the great importance of thorough cleanliness, and who doubt that a brush, after having been used once for removing purulent substances from the surface of the body, can properly be sterilized, advise their use only once. This limitation in the use of brushes proving expensive, small bundles of sterilized compressed wood-wool were devised as substi- tutes for brushes. These wood-wool brushes, being cheap, may be thrown away after the scrub- bing. But it is evident that for the removal of tightly-imbedded filth from small folds, grooves, and edges of the body nothing can substitute a brush in efficacy ; certainly such material cannot be dislodged with anything but a brush. Brushes — preferably those consisting of hog-bristles mounted in a back of wood — should permanendy PROPHYLACTIC DISINFECTION. 103 lie in a bichloride solution. Should they come in contact with infectious material, they must be boiled according to the principles described in Section V. The most indispensable factor in all the pro- ceedings in disinfection is cleanliness in the ap- plication of the means by which it is attained. There should be attached to every wash-stand an enamelled box (Fig. 22) containing bichloride Fig, 22. — Enamelled brush-box (Lautenschlager). (i : 1000), in which the brushes may be placed after beino- sterilized. The solution must be renewed at least every twenty-four hours. However, every attention to appliances, instru- ments, and dressings will prove futile if equally strict care is not taken by the surgeon of his body, particularly the parts which approach the patient. During operation a basin with sterilized water should always be within reach of the sur- geon, so that he may frequently cleanse his hands. A well-disinfected brush should lie in each basin. Basins containincr a solution of bichloride should 104 SURGICAL ASEPSIS. always be ready in abundance. The bichloride in such basins should be stained with fuchsin, so as to make it easily recognizable. Should con- tamination occur during operation, as from the bursting of an abscess, for instance, simple wash- insr in this solution does not suffice, but the whole disinfecting procedure, as described in the begin- ning of this section, must be repeated, not only by the surgeon, but also by his assistants and by the nurses. V. DISINFECTION OF INSTRUMENTS AND DRESSINGS. The principle which occupies the front rank in Section IV. — namely, mechanical removal first of all — is of equal importance as regards cleansing the instruments. Pus, blood-coagula, fat, and necrotic tissues adherent to instruments must be removed me- chanically by washing with ordinary water. It is vi^ell to hold the instruments under the full stream of the hydrant while this v^ashing is being done ; then they must be put into hot water to which soda and soap are liberally added ; in this fluid the instruments must be brushed energetically ; then, after being washed again under the hy- drant, they must be rubbed with sapolio or polish- ing powder, or some similar substance, and alco- DISINFECTION OF INSTRUMENTS AND DRESSINGS. 105 hol. A piece of leather should be used for this purpose. To be radical, washing in the soda- solution may then be repeated, and the instru- ments be dried thoroughly. Naturally, the instru- ments cannot be otherwise than absolutely clean after this procedure ; but they still are far from being sterile, as is shown by Schimmelbusch's bacteriological examinations of instruments clean- ed in this manner. After having dipped instru- ments thus cleaned into liquid gelatin he could always obtain cultures of microbes. As stated in Section III., the most powerful and the promptest bactericidal agent is boiling soda-solution. Schimmelbusch proved that all pyogenic microbes die in a i per cent, boiling soda-solution in two or three seconds. Even the spores of the most resistant microbe, the bacil- lus anthracis, are killed surely in two minutes. This solution and an enamelled cookinq-pot (Fig. 63) may be obtained everywhere. The size of the pot naturally depends upon the character of the operation and the amount of the parapher- nalia required ; as a rule, a pot about fifteen inches long, seven inches wide, and five inches deep is suf^ciently large. Very long instruments are not generally used by the surgeon, but only by the obstetrician, for whose instruments a fish- boiler would be preferable. Before the instruments are placed in the pot I06 SURGICAL ASEPSIS. they should be put into compresses or Hnen bags held together by satety-pins or bound together with a string, the ends of which can be squeezed in between the edges of the pot and its cover. The strings may serve as draw-strings by which the suroreon is enabled to lift the bacr from the sterilizer. Naturally, the bag must be opened with well-disinfected hands only. To the boiling water in the pot is added pulverized soda — that is, the carbonate of sodium (Natrum carbonicum siccum, P. G.) — one tablespoonful to the quart. P'iG. 23. — Glass tray. If this pure preparation cannot be obtained, ordi- nary crystallized soda must be taken, three table- spoonfuls to the quart. In this solution the use- fulness (particularly the sharpness) of knives, which have to be boiled just as well as other in- struments, will not be impaired, especially if they are put into the sterilizer on a separate frame, so as not to be in direct contact with the other instruments, especially those which have hard surfaces. If they are handled roughly and are DISINFECTION OF INSTRUMENTS AND DRESSINGS. 10/ carelessly put into the basins, and if the blades are wiped off too forcibly, the cutting instru- ments — knives, scissors, sharp spoons, chisels, etc. — are soon ruined. Instruments having the so-called "French locks" require particular care around their joints. After the water has boiled for a few minutes the pot is placed in a basin containino- cold water and there left until it has cooled. The instruments may then be taken directly from the pot, or they may be enveloped in a towel as described above, and be taken from the towel with sterilized forceps when required. In hospital the writer prefers to put instruments upon large, sterilized dry compresses covering the bottom of a thick tray of glass (Fig. 23), agate-ware, porcelain, or hard rubber, which can easily be disinfected by previous boiling in a soda-solution. It is customary now to term such disinfection sterilization. As a rule, the term "disinfection" is applied to infected organs, cadavers, clothing, etc., while the term "sterilization" is applied to surgical instruments, culture-media, and fluids such as water, milk, etc. A sharp line of demar- cation, however, is with difficulty drawn between these procedures, both tending to the same end. Whenever blood, fragments of tissue, or any other substance adheres to an instrument, it must be cleaned mechanically in sterilized water. I08 SURGICAL ASEPSIS. Surgical instruments should consist only of metal. Their disadvantao^es are in beinor some- what heavier than the old-fashioned wood- or bone-handled instruments and in their tendency to become slippery when wet with blood. The difference in weight, however, and the incon- venience above mentioned are compensated for by the facility of sterilization, which is practically impossible with the instruments formerly used. Fig. 24. — Von Farkas' steam-atomizer. Notches and grooves should be avoided, and carved handles should have places assigned them in museums. The construction of instruments should be as simple as possible, and no greater variety than is absolutely necessary should be employed. Automatic appliances should be avoided, and it should always be remembered that the hands, and not the instruments, of the DISINFECTION OF INSTRUMENTS AND DRESSINGS. lOQ surgeon perform the operation. Schimmelbusch has shown that such simple instruments as probes and curettes carry very much fewer microbes than do compHcated instruments such as scissors or forceps, which consequently require much more disinfection to render them safe for use. A well-trained surgeon is able to do a great deal of good work with the simplest instruments. If circumstances compel the surgeon to operate with wooden-handled instruments, his duty, at all events, is to boil them, and risk the possibility of the handle and the metal separating. If, however, glue has not been used in connecting the metal part of an instrument with its wooden handle, a short boiling does not affect the utility of the instrument. Instruments with attachments such as ^nirrors, electric lamps, etc. cannot be kept sterile, but much may be done by careful mechanical cleans- ing. Their handles, however, can be so sur- rounded by sterilized gauze that contamination can be avoided. For sterilizing even so compli- cated an instrument as the cystoscope Nitze has recently devised an ingenious apparatus. Rubber catheters can be made sterile by con- necting their distal end with the mouth-piece of a steam-atomizer, Von Farkas' steam-atomizer (Fig. 24) being the most advisable one. Nickel-plated instruments are not a necessity I 10 SURGICAL ASEPSIS. nowadays, as the addition of soda to the boiling water prevents rusting. They are a desirable luxury, however, especially for instruments which are not in every-day use. Instrument-cases should be so made that they may easily be cleaned. The best manner of pre- serving instruments is to keep them in cabinets composed of glass plates and iron. Tin is the best material for instrument-cases (see Section IX., p. 155). Dressing material cannot be sterilized so easily as instruments. The generally accepted manner of sterilizing such material is by exposure to steam. The advantages of this powerful agent have been discussed in Section III. (see also p. 1 2 1 ). If, in private practice, a sterilizer such as described below is not at hand, a fish-boiler may be used for the purpose of sterilizing the mate- rial, or, if even this cannot be obtained, a simple boiling-pot whose cover fits Y^ accurately may answer. If a Mf^^^^J^^ stand made of iron or tin is %h^?'*^^^W inserted into the pot, it can be t^' ^ L used for sterilization by steam Fig. 25.— Beck's folding also. Such Stand should con- improvised stand. ^j^^ ^f ^ perforated disk rest- ing upon three legs about three to four inches long (Fig. 25). This stand can be lifted by the holder reaching almost to the cover. The holder DISINFECTION Of INSTRUMENTS AND DRESSINGS. I I I and the legs may be folded together, and the stand then occupies such inconsiderable space that it can easily be carried in a bag among the instruments, etc. It is advisable to have two or three different sizes of stands at hand for private practice. The level of the soda-solution in which the instruments are boiled should be at least one inch below the disk, upon which the dressing materials, the towels, sponges, silk, etc. are placed. To facilitate free access of steam to the least permeable materials, such as towels, the writer finds it useful to place between them per- forated tubes. As the instruments do not re- quire as much time for sterilization as do the dressing materials, they may just as well be boiled in a separate pot (p. 291). While the simple boiling- pot is as effective for ster- ilizing dressing material as a more expensive apparatus, it does not, however answer the requirements of a hospital so far as convenience is con- cerned. The simplest appa- ^^ ratus of its kind is the steril- izer of Koch (Fig. 26), but "^^ , . - Fig. 26. — Koch's sterilizer. the most approved one tor such purposes is the one devised by Lauten- 112 SURGICAL ASEPSIS. schlager (Fig. 27). It consists of two copper cyl- inders, one inserted into the other, and both sur- rounded by a varnished hnoleum cloak. The inter- space of about two inches between the cylinders is filled with water to the rtiiddle of the apparatus, the level of the water being shown by the glass o-auge attached to the external surface of the outer Fig. 27.— Lautenschlager's steam sterilizer for dressings {A, exterior view, B, cross-section). cylinder. The steam, after rising into the small space surrounding the interior copper cylinder, passes through the holes of the upper part of the apparatus and enters the inner cylinder intended for the reception of the dressing materials. After placing the cover on the apparatus, the steam cannot escape upward, but passes through a tube DISINFECTION OF INSTRUMENTS AND DRESSINGS. I 13 attached to the floor of the sterihzation space ; thence it Is conducted through the coils of a lead pipe into a cooling-vessel containing water for condensing the steam. The cover, which fits her- metically, is fastened down by strong screws, a thermometer being attached to the centre of the cover. When the water is heated by gas or by alcohol the interior space containing the materials to be sterilized is heated before the steam enters. Thus, articles subjected to ^' pre-heating " [Vor- wdrmen, Schimmelbusch) are subsequently ex- posed to the steam. The time required for thoroueh sterilization of dressinor material in this apparatus is forty-five minutes. In hospitals, where steam can be obtained from a boiler, the Lautenschlager apparatus is preferred. This apparatus, which has been used in the surgical wards of St. Mark's Hospital for the past three years, has given perfect satisfaction. After the dressing materials, etc. are sterilized, it is of great importance that they afterward be kept so. The way in which sterilization is gen- erally maintained is by keeping the materials in bags, baskets, cans, or boxes. The habit of many surgeons is to pick the dressing from its receptacle as required at the time of operation, and, placing it on the table, to cut such pieces as are needed. If this practice is followed, control of the nurses in charge of this work is absolutely 114 SURGICAL ASEPSIS. impossible. No matter how clean a table is, it certainly is not more sterile than an instrument- cabinet, even if the table consists of nothing but steel and iron. It is not conceivable that material kept or handled thereon can remain free from mi- crobes. The safer way to obtain sterile material is to sterilize it in the apparatus jtcst before it is 7csed. To accomplish this it is best to keep the materials in a perforated tin box such as devised Fig. 28. — Schimmelbusch's perforated FiG. 29. — Schimmelbusch's tio tin box. box in a portable leather case. by Schimmelbusch (Fig. 28), and to place the box in the steam apparatus before using the con- tents. The holes at the top are so arranged that they can easily be occluded by shifting over them a movable strip of tin. After having placed the dressing material, such as gauze and sponges cut into pieces, rolled bandages, etc. in the box the latter is put into the steam apparatus, the holes being open. After the box is taken out the holes are closed, thus rendering the box practically air- tight. There the sterilized articles may remain DISINFECTION OF INSTRUMENTS AND DRESSINGS. 1 1 5 until they are required at the operation. In pri- vate practice such tin boxes may conveniently be carried in a portable leather case as devised by Schimmelbusch (Fig. 29J. Whether heating the material beforehand is really a necessity has, however, been doubted by many good authorities. It is true that it prevents moistening of the dressings, but moist steam has far greater germicidal potency than dry steam. If some care be taken in keeping the objects to be sterilized away from the interior walls of the apparatus, so that they do not come into direct contact with the water used for conden- sation, they will not become wet; but even should this occur, it will work no harm, being dis- agreeable only. As Von Esmarch has shown, steam is rendered less powerful when it is sur- rounded by gas produced by the. heating process. Recent investigations seem to prove '* pre- heating " to be unnecessary, so that such compli- cated attachments as described above might be dispensed with. It is evident that the sterilizing process could thus be rendered much more sim- ple and less expensive. For the purpose of sterilizing insh^umejits in hospitals, Schimmelbusch's apparatus (Fig. 30) seems to be the most desirable. Great stress is laid upon its hermetic occlusion by the cover, as the temperature of water boiling in an open Il6 SURGICAL ASEPSIS. vessel is not equal in every part. The hermetic occlusion in Schimmelbusch's apparatus is ob- tained by a water-filling, which has also the advantage of preventing rapid evaporation of the soda-solution ; were this evaporation not guarded against, refilling would be required whenever the apparatus was used for any con- siderable leneth of time. The burners must be so arranged that the flame can be kept as high or as low as may be desirable. The instru- ments are put into wire a i_ — ___.! baskets (Fig. 30, b) pro- vided with wooden han- llitenimulll llir^---l Fig. 30. — Schimmelbusch's gas-heated apparatus {a) for sterilizing instru- ments ; b, wire basket. dies to facilitate their being placed in and taken out of the apparatus. After the instruments are boiled in this apparatus for five minutes the wire baskets may be taken out and placed on steril- ized towels or on vessels such as those described on page 107. It is optional with the surgeon to keep the instruments in sterilized water, in a solution containing alcohol, or in a solution of soda. Further sterilization is then unnecessary. DISINFECTION OF INSTRUMENTS AND DRESSINGS. 1 1/ Numerous other useful sterilizing apparatus are recommended. The writer need mention only those devised by Korte, Schiiller, Rotter, Straub, Mehler, Kronacher, Ostwalt, Arnold, Fig. 31. — Braatz sterilizer (for dressings and instruments). Meyer, Boeckmann, and Braatz (Fig. 31). Mally of Paris ' advises a sterilizer in which glycerin can be boiled instead of water. Its advantage consists in the possibility of boiling metal, hard rubber, catgut, etc., as well as knives, without impairing their usefulness. The apparatus is constructed similarly to Braatz's dry sterilizer, mentioned on page 126. For private practice it is convenient to have an apparatus which will allow simultaneous ster- ^ Zeitschrift fur Kranke)ipjiege, No. 5, 1894. ii8 SURGICAL ASEPSIS. ilization of instruments, dressing materials, etc. — so-called " universal sterilizers." In addition to the other requirements, such an apparatus must be portable. For the past three years Korte's portable sterilizing apparatus (Fig. 32) has served the writer admirably. It is of such simple construc- tion that it can be made to order by any tin- FlG. 32. — Korte's sterilizer for dressings and instruments. smith. This sterilizer consists of two compart- ments. The lower compartment may be used separately as a simple boiling-pot for instru- ments ; the upper compartment, being destined for the reception of the dressing materials, may be attached to the lower part by merely placing it upon the lower one after having removed the cover of the lower division. The floor of the upper compartment consists of wire netting, DISINFECTION OF INSTRUMENTS AND DRESSINGS. 1 1 9 which allows free access of the steam produced by the boiling soda-solution. The top of the upper compartment is protected by a cover so arranged that by shifting it the steam can escape from time to time as may be desirable, according to the amount of pressure produced. In the upper compartment may be placed towels, dress- ings, sponges, and silk. Room may also be found for two operating-coats if made of thin material. This apparatus, which is heated by alcohol, the feeder being attached to its side, can easily be carried in a canvas cover. The disadvantage of all these valuable appa- ratus, however, is their size, which makes it incon- venient to carry them to operations. Most oper- ations require a sterilizer of considerable size. Fig. 33. — Beck's folding sterilizer [a, apparatus folded ; b, open). Small apparatus, so-called '' pocket sterilizers," permit only of the sterilization of a few sponges and the boiling of the instruments. To remedy I20 SURGICAL ASEPSIS. this defect the writer has devised a folding apparatus the separate parts of which can easily be put together (Fig. -^i). The lower division (^), which is also the smallest one, consists of a reservoir which is half-filled with a solution of soda. A wire net on which the instruments are placed fits into this reservoir, which fits into the next division (i5), which again fits into the larger division (Cj. If desirable, a fourth division can be set up. Wire sieves (^) can be inserted into the projections of the walls of division B as well as those of C to receive the dressings, towels, sponges, etc. To the lower division {A) are attached two folding supports, between which, when in use, is placed the alcohol lamp (6^). The lamp is so constructed as to allow of its being carried with safety when filled with alcohol. Besides the regular attachments — that is, the alcohol lamp, the wire sieves for the dressings, the wire net for the instruments, two hooks for pulling out the latter, and the thermometer — a few instruments, a silk-box, etc. find ample space in division A. After being folded together the height of the apparatus amounts to 6 centi- metres. This height is less than one-fourth of that of the whole apparatus when ready for use, which amounts to 27 centimetres. The sterilizer can either be put into an instrument- satchel or be carried under the arm. Two quarts DISINFECTION OF INSTRUMENTS AND DRESSINGS. 121 of water after eight minutes will be so heated (as indicated by the thermometer fitted into an opening in the lid) as to fill the whole sterilizer with steam of a temperature of ioo° C. (212° F.). Anthrax spores dried on silk ligatures showed no cultures after they had been exposed to the steam for fifteen minutes. As has already been shown, the most valuable material for dressings and sponges is absoi^bent gauze, as it possesses all the elements of aseptic protection. Being a coherent material, it leaves none of its fibres in the wound ; furthermore, it absorbs well and can easily be rendered free from pathogenic microbes. A great many substitutes for gauze have been advised ; of these may be mentioned absorbent cotton, wood-w^ool, turf, moss, savv^dust, white or black oakum, and bran ; also chopped straw, tan-bark, ashes, sea-sand, etc. The best material is not, as is generally sup- posed, the one that immediately absorbs the ereatest amount of fluid, but it is that which ab- sorbs continually and which is apt to dry at the same time. For instance, blotting-paper, although rapidly absorbing an enormous quantity of water, is useless as a dressing material, because its power of absorption ceases as soon as it is com- pletely saturated with the liquid ; moreover, it becomes softened, contractile, and impermeable like pasteboard. 122 SURGICAL ASEPSIS. The absorbing power of absorbent cotton, for which a great predilection seems to exist, is also small, and it cannot be compared with that of ofauze. The most desirable dressing material, next to gauze, is compressed moss, whose absorbent powder is five times as great as that of gauze. Moss is a very soft and adaptable material, and it can easily be sterilized. It may be used either loose, after being put into gauze bags, or, prefer- ably, compressed into a tablet-like shape. The writer for the last few years has also exten- sively employed moss-board as a splint. The board, after being dipped into water, adapts itself to the contours of the body like a plaster-of-Paris splint, over which moss-board possesses the ercat advantacre of beinor absorbent and much lighter. It is indeed an ideal splint (Fig. 34), and in its thick size is especially valuable in com- pound fractures; for, should the discharges exceed the absorbent power of the gauze directly covering the wound, the moss splint takes up the superfluous discharge without impairing the usefulness of the moss as an immo- bilizing factor. After operations in the inguinal ^^:.-5 Fig. 34. — Moss-board. DISINFECTION OF INSTRUMENTS AND DRESSINGS. 1 23 region it immobilizes excellently for protecting the abdomen and thighs, if cut in the shape illustrated by Figure 34. It also dries constantly while absorbing at the same time. It may further be remarked that the price of moss-board is very low. On further indications for the use of moss- board see page 195. For protecting aseptic wotmds common absorb- ent gauze, if properly sterilized, is sufficient; for the treatment of infected zvounds, as will be noted in Section X., gauze must be impregnated with an antiseptic substance, such as iodoform, salicylic or boric acid, etc. Iodofo7nn gauze is prepared best by dusting the well-pulverized iodoform powder over the com- mon absorbent gauze and then rubbing it into the meshes, by means of sterilized gauze mops, until the gauze has assumed a yellow color. It is, of course, much more convenient to prepare iodoform gauze by simply dipping it into an emulsion of glycerin or into an ethereal solu- tion of iodoform ; but the addition of glycerin seriously impairs the power of absorption, and gauze impregnated with an ethereal solution de- composes easily. Iodoform gauze may, after being rolled up in a piece of gauze, be sterilized in steam. Ster- ilization should, however, not be kept up longer than is absolutely required, as decomposition 124 SURGICAL ASEPSIS. may be caused by it. The gauze may be pre- served in sterilized jars, but it is preferable not to keep a large stock, but to prepare it anew as required. A strength of lo per cent, is gener- ally sufficient. It should be borne in mind that the higher the percentage of the iodoform, the weaker becomes the absorbing power of the o^auze. The indications for the use of iodoform eauze will be described fully in Section X., on Treat- ment of Infected Wounds, and in Section XL, on Open-wound Treatment. Gauze can be impregnated with almost any antiseptic drug. Besides iodoform gauze the writer uses only salicylated or dei^matol gauze ^ and this only when a substitute for iodoform gauze is required — as, for instance, in the event of the occurrence of eczema, which may sometimes be produced by the use of iodoform (see pp. 86, 227). Salicylated and dermatol gauze is made up reliably by most druggists. Bandages should be kept in stock In large quantities. They can easily be sterilized in steam. Various lengths and widths are required, and they should consist either of common absorbent gauze, of starched gauze, or of Canton flannel. STERILIZATION OF CATGUT, SILK, ETC. 1 25 VI. STERILIZATION OF CATGUT, SILK, ETC. With the advent of the aseptic era the desire for absorbable sutures and Hgatures was natu- rally more strongly developed than ever before. Rhazes in 1813, and later Hennen, Young, Law- rence, Astley Cooper, and Dupuytren, had sutures made of an organic material consisting of leather or of gut, but their experiments did not prove very encouraging. Joseph Lister established the repute of gut by claiming that after its disinfec- tion in carbolic acid it admirably serves its pur- pose without being a source of infection. There can be no doubt that catQ^ut is one of the most desirable materials in surgery, and noth- ing has yet taken its place. It would indeed be "the ideal suture" but for the objection presented by the great difficulty it offers to sterilization. More than one hundred methods have been advised, but the great number offered is always the best proof of the weakness of each. Raw " catgut," as ordinarily obtained commercially, is infected with the microbes of its source — namely, the submucous coat of a sheep's intestine ; fur- thermore, it contains much fat. The latter may easily be removed by soaking the gut for forty- eight hours in ether, but it still remains to be proven whether the microbes in cateut can be o destroyed with absolute certainty. 126 SURGICAL ASEPSIS. Of the many sterilizing methods advised and most extensively used, there may be mentioned the following: After the fat has been removed by immersion in ether the gut is soaked in an alcoholic bichloride solution (i : lOo) for forty- eio-ht hours and is then preserved in alcohol. Fig. 35. — Braatz's metal box for sterilizing and keeping catgut sterile. Another method, which is deserving of more con- fidence, is to boil the catgut in alcohol. This is done by putting the catgut in a strong glass bottle containing alcohol. After the tightly-closed bottle has been kept in boiling w^ater for fifteen minutes the catgut is assumed to be sterile, according to bacterioloofical examinations on artificial soil made of catgut so treated. The chance of the catgut being well sterilized is increased by repeating the boiling process on several days in succession. Braatz^ devised an apparatus (Fig. 35) which, ' Die Grundlagen der Aseptik. STERILIZATION OF CATGUT, SILK, ETC. 127 he claims, renders catgut absolutely sterile, useful, and durable. After having extracted the fat from the gut with ether, he winds it on metal rolls. These rolls are placed in the metal box, whose cover is hermetically closed, so that no dust can enter. The amount of catgut needed only at one time is drawn throug-h a small hole in the side of the box and is cut off; thus the catgut remain- ing in the box continues uncontaminated, and Fig. 36. — Braatz's apparatus for sterilizing catgut. therefore sterile. When it is proposed to sterilize catgut the metal box containing it is put into the dry sterilizer (Fig. 36). The catgut can also be preserved in the same box in which it has been sterilized. The principle of the operation of 128 SURGICAL ASEPSIS. Braatz's apparatus consists in the fact that one wall of a flat metal box filled with liquid paraffin lifts and lets fall a cone with the fall and rise of the temperature in the apparatus. The supply of gas is thus automatically regulated, keeping a uniform temperature, which is supposed to be an important point in dry sterilization. A much favored way of preserving catgut in alcohol is to keep it in glass jars having hard- rubber caps (Fig. 2)7)' The writer, however, pre- fers to use the metal box (Fig. 42), devised by himself, which is a modification of Braatz's and which can also be used for silk (seep. 136). But even when cultures could not be obtained from catgut prepared in the above manner, suppuration result- ed from its use, as reported by Kocher and Klemm. Klemm used catgut steril- ized in bichloride and alco- hol, and kept it in alcohol for several weeks. With sterilized scissors he cut several small pieces of this gut and placed them on different soils — namely, on pep- tonized gelatin, agar-agar, and bouillon. The soils thus inoculated were observed in ordinary Fig. 37. — Glass jars for catgut. STERILIZATION OF CATGUT, SILK, ETC. 1 29 temperature as well as in an incubator kept at a constant temperature of 98° F. No cultures appearing in three weeks in the test-tubes nor on the Petri plates, the catgut was deemed sterile; it was then used in operations such as ampu- tations, herniotomies, etc. Notwithstanding the strictest aseptic precautions, it was repeatedly found that locally as well as generally everything appeared normal during the subsequent five or six days, but between the seventh and tenth days there occurred a slight elevation of temperature. The vicinity of the wound became swollen and red, and upon separating its edges there was revealed the presence of a deep-seated abscess. It was clearly evident that suppuration had taken place around the catgut sutures ; while in the skin, where silk was used, no suppuration was discovered. It was then deemed possible that infection had originated from the centre of the catgut suture. As absorption of the catgut be- gins at its periphery, it might be assumed that microbes locked in the centre of the gut were set free when absorption reached that part of the suture. This would be in harmony with the fact that signs of suppuration generally appeared a week after the insertion of the sutures. To as- certain the correctness of this assumption slices of catgut prepared in the manner previously described were pulled into small pieces by steril- 9 130- SURGICAL ASEPSIS. ized pins and put on the same soil, but the result was negative. The following experiments were also made by Klemm at the surgical clinic in Dorpat, where, so long as silk was exclusively used, suppuration was only exceptionally observed : A number of cats, toward whom the same strict aseptic precautions were observed as is done in operations upon human beings, were treated by making in both thighs long incisions reaching down to the muscular tissue. A me- dium sized sterile catgut suture was implanted in the wound of one thigh, while a silk suture was buried in the other: four days later the animal became weak, refused nourishment, and died a few hours after the first symptoms of infection appeared. Where the catgut was im- planted nothing abnormal was observed on the superficies, but after opening the united edges of the wound there escaped a brownish liquid of an offensive odor. The cellular tissue was also dis- colored and cedematous. After having exposed the muscular layer into which the catgut was implanted, and which showed the same change, the catgut was found sodden, of an offensive odor, and of a reddish- brown color. The silk implanted into the other thigh presented nothing abnormal. The frag- ments of catgut, as well as those of the silk, STERILIZATION OF CATGUT, SILK, ETC. I3I were removed with sterilized instruments and put into separate Petri plates filled with gelatin. Two days later the plate containing the catgut fragments showed a rich colony of pathogenic microbes, while the one with the silk proved sterile. These experiments caused Klemm to maintain that, while catgut may be sterile, it is a favorable soil for the establishment of micro- organisms. It is an organic membrane, and under the influence of moisture and warmth it is very prone to decomposition should it come into the slightest contact with micro oro-anisms. As the normal tissues of the body shelter no micro-organisms, the theory was advanced that they reached the catgut through the air, and that in connection with this material the pos- sibility of infection from the atmosphere was greater than was attributed to this source. At any rate, the action of chemical reagents in test-tubes may be prompt, while their action is questionable upon micro-organisms within a wound. A wound has no dead soil, as has a test-tube contai7iing gelatin. Furthermore, test- tube experiments must needs differ from the conditions found in a wound, where the mi- cro-organisms encounter living tissues. It is still an open question whether Klemm's and Kocher's experiments demonstrate the propriety of discarding a material that offers such decided 132 SURGICAL ASEPSIS. advantages as does catgut. It is possible that the catgut of these experimenters was infected, de- spite all the precautions reported, and that greater care, as well as sterilization by heat, would per- haps have rendered it just as safe as silk. Be it as it may, the above experiments show that sterilization of catgut requires such great care as to prevent a considerable number of surgeons from using it altogether, or at least intraperi- toneally. The great fear of imperfect steriliza- tion — a fear strengthened by reports which traced suppuration and even death to the use of catgut — induced the writer to forego the use of this material, to his great regret, in operations where concealed sutures are used — that is, just where catgut displays its most desirable quality. If after an abdominal section the abdomen be closed, the site of an infection caused bv a cato-ut ligature cannot be discovered at a period early enough to allow of effective disinfection ; while if used on the skin surface only, the symptoms of infection from catgut are so early perceived that by such procedures as immediate removal of the infectious material, opening of the wound, etc. general infection may be prevented. In opera- tions on the surface, however, the only advantage possessed by catgut over silk consists in the fact that removal of the sutures is unnecessary after they have served their purpose. If, as may con- STERILIZATION OF CATGUT, SILK, ETC. 133 fidently be expected, an absolutely reliable meth- od of sterilization is invented, catgut will repre- sent the most perfect ligature material. Silk can very easily be sterilized by winding it on glass spools and boiling it in a soda-solution for at least five minutes. Silk is used in various sizes, according to the vessels or pedicles to be tied. As it can be boiled with the instruments just before it is required, the question of its preservation in a sterile condition is unim- portant. In hospitals, botdeS Fig. sS-Ligatme-bot- with ground-glass stoppers and tie with ground-glass stop- spools on glass racks (Fig. 38) ^f^' "''^, °"' '^°°^ °" ^ ^ \ & vj / glass rack. are frequently used to pre- P"iG. 39. — Aseptic case for silk sutures. serve sterilized silk. Some surgeons prefer to keep it in test-tubes stoppered with rubber corks w^hich may be carried in an aseptic suture-case 134 SURGICAL ASEPSIS. (Fig. 39). Others prefer to keep silk on reels of polished plate glass (Fig. 40) which can be carried in sterilized paper or linen or in small metal boxes. Schimmelbusch^ recommends sterilization of silk in steam. The silk threads are wound on rolls attached to a metal box (Fig. 41), which is put for three- ^^ quarters of an hour in the ster- ilizer, where it can be sterilized Fig. 4o.-Reeis of with the dressings, etc. Silk polished plate glass remains sterile and dry in these with three cuts for , ^r^i r i • • i various sizes of silk. ^oxes. The fact that It IS dry materially facilitates threading it into needles and tying. The writer has devised a metal box which, by combining the advantages of Schimmelbusch's apparatus for silk and that of Braatz for cat- gut, can be used for sterilizing and preserving catgut as well as silk (Fig. 42). Silk is certainly the safer material, and It is far preferable for ligating large blood-vessels, in which operation too early absorption of a catgut ligature might prove fatal. Although silk Is not absorbed in the majority of cases, if strict asepsis has been observed It will be encysted, and thus practically fulfil the same requirements as though it were absorbed. It, furthermore, has the advan- ' Aseptische Wundbehandlung. STERILIZATION OF CATGUT, SILK, ETC. 1 35 tage that even thin silk may be used for the ligation of large blood-vessels. The impossibil- ity of using catgut in delicate plastic operations, in which only the thinnest kind of silk is advis- able, makes the latter exceptionally useful for this special purpose. Fig. 41. — Scliimmelbusch's metal boxes for sterilizing silk and keeping it sterile {^a, box closed ; b, box open). Recently, simple thread has been recommended as a substitute for silk, on account of its lower price and because it can be sterilized as thor- oughly as silk. But silk can be handled better and can more easily be tied. 136 SURGICAL ASEPSIS. Si/kwo?'7n gilt, which is furnished in bundles like the reels used by anglers, can very easily be sterilized. Some suroeons favor silkworm-orut because of its smooth surface and its density, Fig. 42. — Beck's metal box for sterilizing and preserving catgut and silk, deeming it on this account the least irritating of sutures. Silver wire may quickly be sterilized in boiling water. It is not at present so extensively used as formerly, when silk was not so easy of steril- ization. The writer still finds it very useful for sewing bone-fragments and for "buried sutures" in operating for ventral hernia. It may also be used in plastic operations as a relaxation-suture or as a propliylactic suture (see p. 166). DRAINAGE AND IRRIGATION. 1 3/ The use of parchment sutures, of threads made of the aorta of the ox, or conslsthig of horse- hair, kangaroo-tendon, etc., is merely a matter of choice. VIL SPONGES, DRAINAGE-TUBES, AND IRRIGATION FLUID. Sponges. — There can be no doubt, from a strictly technical standpoint, that ordinary marine sponges, such as are generally used, are the best material for the purpose of sponging, being elastic and possessing immense absorbent power. Their sterilization, however, is very difficult, if not uncertain. The safest method of sterilizinor sponges would be by boiling in a soda-solution for ten minutes; but as this procedure materially reduces their elasticity, and as shrinkage hardens them, their usefulness is much impaired by such sterilization. Schimmelbusch therefore advises the following method : Sponges, as ordinarily purchased commercially, are freed from dirt by beating out the sand and shells in their alveoli. They are then soaked for several days in cold water slightly acidulated with muriatic acid, and arc kneaded from time to time. They are then washed thoroughly, first in cold and then in warm^ water, until the water remains clear. They are then enveloped in a linen sheet and put into 138 SURGICAL ASEPSIS. a boiling i per cent, soda-solution. To limit shrinkage while boiling, it is advisable to take the boiling solution from the fire shortly before the sponges are immersed. After remaining in this hot solution for thirty minutes they are squeezed out and freed from the soda by again immersing and squeezing them in boiled water. They may then be kept in a ^ per cent, bichlo- ride solution. Regarding the uncertainty of sterilization, care- ful surgeons do not care to use marine sponges after they have come in contact with infectious material. But to discard sponges after having employed them only once is extravagant, con- sidering their price ; it is quite natural, therefore, that most surgeons have given up ordinary sponges, and in their stead use only small steril- ized gauze mops, which admirably answer all the purposes of sponges. As tampons in hemorrhages and for opera- tions on the mouth and the pharynx, marine sponges are of considerable value, especially when fastened to a sponge-holder. The writer during the past few years has been satisfied to operate without using a single marine sponge during operation, as the fear of insufficient ster- ilization outweiofhed all other considerations. Gauze used for ordinary surgical dressings may be sterilized according to the methods de- DRAINAGE AND IRRIGATION. 1 39 scribed in the previous section. If kept in the steam of a steriHzer for thirty minutes, the most resistant spores in it will be killed. Mops may be made of a number of folds of gauze loosely hemmed at the edges. They should be so cut as to preclude the risk of leaving loose threads in the wound. For the abdominal cavity gauze pads from six to ten inches square are useful. The orreatest advantag^e of this material is that after being used it may be thrown away, its cost beincr insio^nificant. Small bao-s filled with moss or with wool may serve just as well, and they are somewhat cheaper. A supply of such mops may always be kept in a glass jar, but it is preferable to sterilize them shortly before they are used. Drainage-tubes seem to be almost as near the stage of surgical extinction as are sponges. Nothing characterizes the lukewarm aseptic sur- geon more than his predilection for drainage, which, in fact, means nothing less than that he lacks confidence in his own system of asepsis. If, on the one hand, no antiseptic irritants have been used during operation, if all aseptic pre- cautions have been observed, and if no wound- pockets have been left, discharge from the wound is practically nil, consequently such a case will not give rise to anything that needs to be carried off by a tube. On the other hand, 140 SURGICAL ASEPSIS. if operations in infected or suppurating areas are to be performed, drainage will be a necessity, but even then it should not be effected by rubber drainage as a rule, but by gauze packing, as shown in Section XL, on Open-wound Treat- ment (pp. 190 and 218). Still, surgeons cannot entirely do without drainage-tubes where neither union by first intention is to be expected nor thorough packing with gauze is to be performed. The most desirable tubes, then, are those made of soft India-rubber. They must be as wide as possible, and they should be fixed at the most dependent part of the wound. They may be fastened in the wound either by sewing them to the skin or by transfixing one end of the tube with one or two safety-pins. It is perhaps need- less to say that the pins must be boiled in a soda- solution before use. Holes should be made in the sides of the tube at short intervals, and the tube should be cut off nearly flush with the skin. Rubber drainage-tubes can easily be sterilized by placing them for five minutes in boiling soda- solution. This length of time suffices for the destruction of all microbes. If the rubber be kept in the solution much longer than five minutes, its usefulness will be impaired. In steam, rub- ber drains require at least twenty minutes for sterilization. After being made aseptic the tubes may be preserved in a 5 per cent, solution of DRAINAGE AND IRRIGATION. 141 carbolic acid. Bichloride is not be recommend- ed, as it forms chemical combinations with the rubber. The best plan, however, is to boil the tube in a soda-solution just before use. Tubes consisting of glass or of hard rubbei^ can easily be rendered aseptic. On account of their rigidity they are preferred by some surgeons, who claim that soft-rubber drains may be compressed in .the wound, thereby caus- ing retention of discharges. The writer has never in practice experienced any retention of pus which could be traced to compression of a soft tube. Whenever retention really occurred, it generally was due to obstruction in the tube, caused by thick or coagulated products of the wound or by other causes (see Section XII., on Change of Dressings). It seems to the writer that the pressure exerted upon a wound- canal by a hard drain is apt to cause sloughing. A great disadvantage of hard drainage-tubes is that they cannot be cut into proper lengths, as can those consisting of soft rubber, consequendy a large variety of lengths of hard tubes must be kept on hand. Drains of decalcified bone are scarcely used at present. They are unreliable and are often too quickly absorbed. Catgut, silk, thread, zvick, horse- hair, and threads of spun glass are used for very small drains ("capillary drainage"), the most 142 SURGICAL ASEPSIS. valuable among them being the wicks, which can be made from ordinary lamp-wicks. The indica- tions for the various forms of drainage, and its technique, will be described in Section X., on The Treatment of Infected Wounds, in Section XL, on Open-wound Treatment, and in Section XIL, on Change of Dressings. Schede recommended the utilization of the moist blood-clot which forms in cavities left after a piece of bone has been removed. He unites the outer edges of the wound above the cavity after it has filled with blood. If aseptic pre- cautions are taken the blood-coagulum remains aseptic and will gradually be absorbed. The clot affords protection to the raw surfaces of the wound, and if it does not contract and desiccate it forms a nidus for granulation-tissue, which develops and finally cicatrizes. It is an ideal method of repair, especially in operations for the removal of necrosed bone without re- quiring a drainage-tube. Irrigation Fluid. — Sterilized water only must be used for the washing of wounds or the skin of the patient, and the surgeon should wash his hands in no other liquid, be it mixed with an antiseptic or not. The fact that underground water is always sterile, showing the efficacy of filtration, has led surgeons to imitate nature by selecting artificially sterilized water for sur- vSURCxICAL ASEPSIvS. Plate \' THE ASEPTIC OPERATING-ROOM. I43 gical purposes. But no apparatus constructed on the plan of natural filtration will furnish abso- lutely sterile water. As indicated in Section III., boiling water is the most powerful disinfecting agent; anthrax spores exposed to it for only two minutes are invariably destroyed. Therefore water which has been boiled for five minutes may safely be considered sterile. It is best to prepare such water shortly before the time of each operation. The water may be preserved, however, if, after being boiled, it is kept in clean glass vessels stoppered with sterilized cotton. In large hospitals it is advisable to have a special apparatus for the sterilization of water. A sim- ple boiler in which water can be boiled and then quickly be cooled by a system of water-pipes containing cold water admirably answers the purpose. Water from deep wells, however, is generally aseptic, while stagnant water is loaded with microbes. VIII. THE ASEPTIC OPERATING-ROOM. The operating-7^oom of a hospital {V\. V.) should be at a considerable distance from the wards, to avoid as much as possible disturbance to the ward patients. The most preferable place is the top floor, as, besides the convenience mentioned, good light can be obtained there. It is a great conve- 144 SURGICAL ASEPSIS. nience to have two smaller rooms adjacent to the operating-room — an anaesthetizing room (PI. X., Fig. 2), and another room in which the surgeon and his staff can dress and disinfect themselves. It is also desirable to have a store-room for the materials required at operations. The main requirement of a strictly aseptic operating-room is that its floor, ceiling, and walls may easily be cleaned. All the objects in the room should serve none but surgical purposes, and should be simple and plain. They must be able to withstand either energ^etic scrubbinor or boilino^ in a soda- solution. The floor must easily be drainable and be waterproof Terrazzo or marble is the best material for flooring. The walls should be cemented, or at least be oil-painted, and the corners of the room should be rounded, so that washing is easy. On one side there should be several wash- basins supplied from hot- and cold-water spigots, so that either hot or cold water may freely be used. The basins should be large enough to permit immersion of the hands, forearms, and elbows. Arrangements should be made to have the water-supply of the pipes sterilized before it escapes from the spigots (see p. 142). A wash-sink (with a copious water-supply and with drip-stones nearby for dishes), sterilizers, and vessels for boiling water and soda-solution, THE ASEPTIC OPERATING-ROOM. 145 preferably seated on a wash-stand (Fig. 43), are also required. Neuber advises that there should be attached to the walls large glass shelves on which glass bowls may be placed and into which bowls the water may run. Glass shelves are desirable at Fig. 43. — Simple wash-stand for two enamelled dishes (frame wrought iron, white-enamel finish). all events to hold the glassware, sponges, gauze, drains, ligatures, cotton, etc. Much has been said about the danger of spec-. tators being present in an operating-room. Some surgeons allow the presence of spectators only after they have given assurance that they have not shortly before attended any case of conta- gious disease ; other surgeons demand certain 10 146 SURGICAL ASEPSIS. precautions from spectators — as, for instance, that they shall put on aseptic coats ; and some surgeons do not admit spectators at all. There can be no doubt that the fewer the persons there are in attendance the better it is for the patient; at the same time, it is in the interest of humanity that students be admitted, as the necessary expe- rience can be acquired only by their presence as frequently as possible at surgical operations. That spectators may carry microbes into the operating-room on their clothing and their bod- ies cannot be doubted. After having attended pathological rooms, such as sick-rooms or even autopsy-rooms, pathogenic microbes must abun- dantly adhere to the clothing, the hair, etc. If this clothing comes into contact with an object to be used at the operation, all aseptic precau- tions previously taken may prove to be valueless. The patient himself may carry microbes on his body, in the wound, or on the dressings. If the patient's dressings be changed, fibres of gauze or of cotton or scales of epidermis may be set free and be disseminated in the air, eventually to settle upon some one's clothing. Furthermore, when windows are kept open a considerable amount of dust containing organic substances from the excretions of animals may invade the room, and settle upon an object which may come into contact with a wound made or to be made. THE ASEPTIC OPERATING-ROOM. 1 47 Neiiber, one of the most distinguished pio- neers of aseptic principles, considers the arrange- ment of the operating-room to be the main requisite for success. He lays great stress upon having separate operating-rooms — one at least for septic and one for aseptic cases, each pos- sessing separate furnishings and supplies. There can be no doubt that it is desirable to have at least two operating-rooms, and to have the arrangements made in the manner described above. Although much may be said in favor of Neuber's theories, they cannot be sustained in practice ; and, fortunately, the recent investiga- tions of Petri and Cleves-Symmer prove that they are not the sole essentials of success. Petri not only fixed the special forms of micro- organisms suspended in the atmosphere, but at the same time he also ascertained the number of microbes present in a determined volume of air. His method of determining the presence of 7nicro-orga7iisms consists in pumping a meas- ured volume of air through a filter of sterilized sand. This sand (to which all the micro-orean- isms of the air adhere) is equally distributed on Petri plates containing sterilized gelatin. On this gelatin the microbes multiply by forming as many separate colonies as there are microbes, which may then be counted. The next question to be determined is that of 148 SURGICAL ASEPSIS. the 7iU7nber of microbes which will settle within a fixed time upon a wound-surface of a cer- tain area. In determining this question a par- allelism could not be assumed between the mi- crobe-capacity of the air and the quantity of the deposits. It would naturally be expected that air containing but few microbes would deposit but few upon wounds, and vice versa. But it has been shown practically that this parallelism does not always exist, as most probably the microbes are not equally distributed in the air, some regions being densely and others sparsely populated. This fact can best be shown, according to Cleves- Symmer, if several gelatin plates are exposed at the same time and the different plates are kept in the same part of the room. A great difference as regards quantity and quality will then be found, for neither the same kind nor the same quantity of microbes will settle upon the plates. Cleves-Symmer exposed gelatin plates for seven days simultaneously in three surgical wards. This exposure was made five times a day, the first at 5 a. m., while the patients were asleep, and the second at 7 a. m., after the floors were first washed and then scrubbed. Similar exposures were made at 9 a. m., when operations were generally performed, and the last exposure was made late in the afternoon. The sterile gel- THE ASEPTIC OPERATING-ROOM. I49 atin was contained in round, flat, large-surface Petri dishes. After the dishes had been exposed each time for twenty minutes they were covered and preserved in a moist incubator the temper- ature of which was that of the room. The developing colonies, as soon as they could be recognized by the naked eye, were counted daily, and were observed so long as they could be distinguished from one another. Among 4613 microbes so counted there was found but one pathogenic micro-organism, which was the bacillus pyocyaneus. At a time when nearly every third case in the hospital suffered from a wound in the discharge of which this bacillus was contained there were certainly ample opportunities for it to permeate the air; if, despite this, a pathogenic microbe was found but once, it is proof enough that the air necessarily contains very few pathogenic mi- crobes. The writer's experience in St. Mark's Hospital, New York, accords with this proposi- tion. The average results of operations in its old building, the very poor accommodations in which premised all the elements of atmospheric infection, were nearly as good as those obtained in the well-equipped new building. The operating-rooms of Billroth at the old "Allgemeines Krankenhaus " in Vienna were far 150 SURGICAL ASEPSIS. from being an anti-Infectious ideal. The same re- mark applies to the greater majority of the prom- inent European hospitals — for instance, the cele- brated Albert Amphitheatre in Vienna, and the clinic of the eminent surgeon Gussenbauer in Prague, as well as the surgical workshops which the writer saw in some Italian hospitals. Success, fortunately, depends not upon the marble floor of a modern operating-room and upon more or less complicated apparatus, but upon carrying out the principles of asepsis so far as direct contact with wounds is concerned. This fact explains why, under the most unfavorable circumstances, Bassini in Padua was able to per- form hundreds of herniotomies in succession without meeting with a single fatal result. At the new St. Mark's Hospital, which really merits the designation of a " model hospital," particularly with reference to modern aseptic appliances, the death-rate is now about the same as it was in the old hospital. This uniformity must certainly be due only to the rigid observation of aseptic principles in reference to all objects that come into contact zvith the wound, such ds the hands of the surgeon, the instruments, and the field of operation. One of the gynecologists at the old St. Mark's Hospital two years ago, under very minute asep- tic precautions, performed three hundred lap- arotomies in succession with a mortality of 8 THE ASEPTIC OPERATING-ROOM. 151 per cent. If, as this rate shows, asepsis depends not upon aseptic operating-rooms, but mainly upon minute precautions in reference to the con- tact question, there is no reason why success should not be obtained in the poorest abode. The whole matter converges to one point — namely, that operations performed in a tenement- house entail a great deal more trouble to the surgeon, while in a hospital everything can be carried out with the greatest convenience. It is quite natural, therefore, that a surgeon, when he has the choice, prefers operating in a hospital. If after a laparotomy the patienf s abdo^nen has been closed, his fate is determined, and the condi- tion of the surrounding atmosphere will be a matter of indifference. If the operation was not done aseptically, no kind of after-treatment, nor any secondary opening of the cavum abdominis, will remedy this omission. If danger of infection really threatened from the air, the danger would naturally be greater in hospitals, which shelter many more microbes, than in a dwelling-house. In private practice it would be advisable to select a laree room with orood lior-ht for an operating-room. If possible, there should be another room for the occupancy of the patient after operation. Many surgeons recommend the removal of all furniture, paintings, carpet, etc. They even go so far as to wash the walls with 152 SURGICAL ASEPSIS. bichloride and to scrub them afterward with crumbs of bread (E. von Esmarch). If these procedures are undertaken a day or two before the operation, nothing can be said against them, but if they are done only a few hours before the operation, they certainly are apt to impregnate the atmosphere with many more microbes, for these procedures whirl up dust, which under such circumstances may become a potent carrier of micro-organisms. Therefore it is by all means preferable to leave the operating-room undis- turbed shortly before operating, and to exercise great care that the tables and chairs, and what- ever else may be required for operation, are covered with sterilized sheets or towels. If ster- ilized linens are not obtainable, freshly washed and ironed sheets will do for all covers which do not come into direct contact w^th the field of operation. The operating-table, and also the small tables upon which instruments are put, should be con- structed of glass and iron, so that they may easily be cleaned with a hot soda-solution or be sterilized in a large steam-apparatus. Chairs upon which instruments, etc. are put should consist of enamelled iron also. Operating-tables should always be made of plain, smooth material, and should not contain any grooves or ornamen- tation. Their tops should be either of metal or THE ASEPTIC OPERATING-ROOM. 153 of plate glass. Numerous tables of this kind, all more or less useful, have been devised, those recommended by Korte (Fig. 44), Sonnenburg, and Edebohls being especially desirable. If such tables are not available, an ordinary strong kitchen table may be utilized, after thoroughly Fig. 44. — Korte's general operating-table, with foot-lever to set table on casters; iron top, white-enamel finish, slanting to the centre, with a metal gutter for drainage ; two detachable drop-plates for operating on the lower limbs ; side table for operating on the arm and hand. scrubbinor it with hot soda-solution. An attach- ment for Trendelenburg's position, such as advised by Cleveland, Boldt, Edebohls, Krug, and others, is desirable. When economical considerations must guide the surgeon, Leopold's simple and inexpensive attachment may be used. It is a frame (fifty 154 SURGICAL ASEPSIS. inches in length and twenty inches in width) con- structed with a hinged flap whose lower part — that is, the part upon which the legs rest — can be brought downward, thus forming a right angle with the upper flap, upon which the pelvis and thighs rest. The flap can be raised sufficiently high by a support. This entire frame can easily be fastened to any kind of table by means of iron clamps. The operating-table should be covered with a folded blanket, a muslin sheet, and a sheet of Fig. 45.— Ordinary dressing- and instrument-table, wrought iron, white- enamel finish. rubber or of oil-cloth. Such sheets may be so pinned together as to form a funnel leading into a pail at the lower part of the table. Kelly's in- flatable rubber cushion may be used for this pur- pose. In its newest form the anterior apron is THE ASEPTIC OPERATING-ROOM. 155 doubled into a large funnel for conducting the discharges into the pail. The instruments used during an operation may be placed upon an ordinary table made of glass and iron (Fig. 45). An instrument- table which is especially useful in hospital^ practice combines a glass case for aseptic dressings with a lifting-top cover and a hinged side shelf (Fig. 46). 5i'** Fig. 46. — Kny's instrument-table. The instruments of a hospital should be kept in an instrument- cabinet composed of iron and glass (as shown in Fig. 47), which may be cleaned easily and thoroughly. The shelves iS6 SURGICAL ASEPSIS. must consist of plate glass, and should be ar- ranged in such a manner that they may be pulled out separately. Splints and apparatus like Volkmann's sleigh, etc. should be kept in an adjoining room. Irrigators are being more and more discarded. Whenever it is possible mechanically to remove Fig. 47. — Kny's instrument-cabinet with adjustable shelves: a plate-glass partition in the centre practically divides it into two closets. from a wound coagula, necrotic tissue, granula- tions, etc. by wiping them from the wound with gauze mops, this method is preferable to irriga- tion. Irrigation, it is true, removes blood-coagula and secretions and brings bactericidal medica- THE ASEPTIC OPERATING-ROOM. I 57 ments into contact with the wound, but at the same time it is apt not alone to remove pus and infectious secretions, but also to force such sub- stances into the tissues, so that further infection is favored rather than prevented. In an infected wound the micro-oro-anisms are sheltered by either the wound-surface, the blood- coagula, the necrotic tissue, or the crusts covering the wound-^ — namely, with material that can never be disinfected by the commonly-used so-called "antiseptic solutions." In large cavities where mechanical cleaning from fibrinous or cheesy masses is indicated — as in pyothorax, for in- stance — the use of an irrigator is desirable at the time of operation, while later on, when such solid masses are removed, no further mechanical cleaning will be necessary. In plastic operations, especially on the vagina, irrigation is also desir- able, as it dispenses with sponging there. The irrigator should always be made of glass, and the scrupulous cleansing of its rubber tube is of very great importance. A thermometer should be connected with it, so that the tem- perature can always be ascertained without the unreliable guess of a helping hand. If opera- tions are performed aseptically and as dry as possible, mechanical cleaning with an irrigator is hardly necessary. For an irrigator there may be substituted a graduated glass jar, which can 158 SURGICAL ASEPSIS. be sterilized very easily, as it does not require any attachments. Large pails should always be ready in the operating-room to receive the removed dressings or other waste material, which should never be thrown on the floor. It is desirable to have such pails removed from the operating-room as soon as they have done service. Each patient, immediately after entering the hospital, should have a bath. This bath is an im- portant preliminary operation before local disin- fection is begun. Bath-tubs (enamelled ones are best) should therefore be at hand in abundance. The wards and the private rooms in a hospital should, as suggested by the principles enunciated above, be so arranged that they can always easily be cleaned. Halls and floors should consist of the same material as that used in the operating- rooms. Beds, tables, and chairs should mainly be constructed of iron. Horse-hair mattresses and Ii7ie7i sheets should be used to the exclusion of all other bed-clothing. If available, two beds should be used for the same patient, as it usually adds gready to his comfort to move him from one bed into another. Good ventilation is essen- tial. The temperature should be kept uniform. From time to time the wards and the private rooms should be disinfected thoroughly, whether they ever contained an infectious case or not. ASEPTIC WOUNDS. 1 59 Mechanical cleansing, as shown on page 6i, is the most important and powerful part of disin- fection. After the floor, the walls, and the ceil- ings, as well as the doors, windows, bedsteads, tables, and other objects, have been scrubbed with hot soda-solution, they should be washed with hot water. The bedding, curtains, etc. must be sterilized either with boiling water or, prefer- ably, with steam. The rooms and their utensils should be aired for several days before use. IX. ASEPTIC WOUNDS. Primary union is the ideal toward which the surgeon strives in treating wounds. This ideal can be attained only when strict aseptic precau- tions have been observed. Primary union occurs after the walls of a wound have been adjusted accurately and a moderate amount of exudation has taken place, resulting in the formation of fibrin, which tem- porarily glues together the edges brought into apposition. If the parts have not been adjusted carefully, blood-corpuscles and masses of coag- ulated fibrin form wherever the walls have not come accurately into contact. Such exudations may organize (moist blood-clot, Section VII., p. 142), but in most cases they impede the healing process just the same as fragments of bruised l6o SURGICAL ASEPSIS, and injured tissue may undergo necrosis in con- sequence of impairment of their blood-supply. To prevent the accumulation of blood in a wound it is essential to stop the bleeding so thoroughly that the wound-surfaces appear abso- lutely dry before they are united. To prevent the formation of necrotic tissue all bruised or injured tissue should be removed, to ensure smooth coaptation of the wound-surfaces. When an incision has been made through the superficial tissues, the margins of the wound separate according to the elasticity of the various structures that have been divided by the incision ; larger vessels must be caught by forceps and be ligated. Hemorrhage from small vessels soon stops without artificial help, as their lumen will close by contraction of their walls, and the arte- ries will retract into their sheaths. Total ob- struction then follows by the formation of a blood-clot within the vessels. After the vicinity of a wound has been washed with sterilized water and the surface of the wound has been wiped off carefully with gauze mops, the bleeding will cease entirely, and then the edges may be united by sutures. In very large wounds, where more than the usual amount of discharge is natu- rally anticipated, deep (buried) sutures must be employed to maintain the deeper surfaces in apposition. If this procedure is omitted, the ASEPTIC WOUNDS. l6l accumulation of the discharge will separate the opposing surfaces. Sometimes pressure alone may answer for this purpose, and sometimes gauze drainage ; and exceptionally a rubber drainage-tube into each corner of the wound will be required to conduct off the wound-product so that the united surfaces may remain adherent. In the regular course very slight, if any, swell- ing of the lips of the wound will follow. The tissue in the vicinity of the incision may be some- what firmer than in its natural condition. This firmness is due to the disturbance in the circula- tion followinof the severinof of the blood-vessels. There should be no discoloration, especially no hyperaemia, of the wound-surface. An occluded wound, very naturally, is better guarded against infection than an open wound. But if microbes have invaded a wound during operation, or if there supervene any of the occurrences above described, occlusion may be detrimental to the patient, as blood-clots, as well as necrotic tissue and the wound-products, are the most favorable soil for pathogenic microbes. Whenever there is doubt as to the invasion of microbes, it is better to omit suturing and to follow the principles explained in Section X. concerning Infected Wounds, and those of Sec- tion XL, on Open-wound Treatment. When it can be ascertained that, despite strict aseptic pre- 11 1 62 SURGICAL ASEPSIS. cautions, abundant discharge is to be expected, or when during operation a microscopic exam- ination has revealed the presence of virulent microbes, the introduction of small drainage- tubes, or preferably of lamp-wicks inserted into the edores of the wound or carried throucrh coun- ter-openings, is indicated. Whenever' doubt exists as to the kind of after -ti^ eat ment, the decision sJiould be in favor of drainage. The possibility of thor- oughly arresting hemorrhage as well as prevent- ing the formation of pockets rests entirely in the hands of the surgeon. Aseptic treatment, how- ever, allows no irritation of wounds, consequently the discharge is generally very scanty. An excellent technique of uniting aseptic wounds, as advised by Neuber, is as follows: After having loosely packed the whole wound with moist sterilized gauze the wound-flaps are united above it by sutures. Small wounds re- quire only a strip of gauze. The edges of the wound are then very carefully adjusted, except at the lowest part of the wound, where it is left sufficiently open to allow the gauze strip to pro- trude. While an assistant presses a few sponges on the united surfaces the gauze is slowly pulled out from the interior of the wound-surfaces. This crauze is now saturated with blood which has been oozing while the sutures were applied. If it should happen that a few fibres remain when ASEPTIC WOUNDS. 163 the gauze is pulled out, these fibres will become en- cysted in the wound without causing any reaction. Forcible compression by sponges covering the united wound-surface is then used once more, to squeeze from the wound-surface all the blood still contained between the interior wound-surfaces. By drawing together the sutures which have pre- viously been applied the wound is closed entirely, and it is then covered with sterilized gauze. If the raw surfaces are of an irregular shape, so that a considerable amount of pressure is required to keep them in contact, it is advisable to fasten marine-sponges, enveloped in sterilized gauze, to the wound by gauze bandages. To secure primary union mastering of the technique of suturing is essential. Of the many methods advised, the following may be mentioned. Continued Suture. — The most desirable method of suturing is by the con- tinued or glover's stitch, as it can be applied very rapidly. The edges of the wound can also be adjusted very easily when this suture is used. When possible, only straight, spear-shafted needles, of the size ordi- narily used by tailors, should be employed. The thread should not be very long, a knot being Fig. 48. — Continued suture with relaxation-sutures. 164 SURGICAL ASEPSIS. fixed at one of its ends. The needle must be inserted at one end of the wound and about one- third of an inch from its edge, which may be seized by strong mouse-toothed forceps. The first su- ture may be appHed as an interrupted suture, but without cuttinor the threads after the knot is tied, or the procedure may be carried out in the same manner as the ordinary tailor-stitch is made. The needle is first carried through one lip of the wound and then through the other, where a loop is formed, through which the end of the thread is drawn so that it can be fixed in a knot. If desirable, a small gap about one-third of an inch in length may be left for drainage. If the wound is very long, the continuous suture may be interrupted by making loops at intervals of three or four inches. In long wounds, or Avhere- ever any considerable amount of tension exists, it is advisable to apply relaxation-siitui'es at inter- vals of one and a half inches in addition to the continued suture (Fig. 48). For such sutures the needle should be introduced three-fourths of an inch from the ed<:re of the wound. While it is convenient to use catgut for continuous sutures, provided it is not applied in cavities like the peri- toneum (see p. 132), the relaxation-suture should always be of strong silk. The continuous suture is especially valuable in those cases where sue- ASEPTIC WOUNDS. ■165 cess greatly depends upon rapidity, as in opera- tions on the peritoneum and the intestines. The interi'ttpted suture (Fig. 49) is the one most commonly used. It can be appHed with either straight or curved needles. Catgut or silk may be used, according to the principles of Section VI. One edee of the wound is seized with mouse- tooth forceps and is perforated with the needle ; then the same manoeuvre is repeated on the op- posite side. If there is little tension, an assistant may so approximate the wound-edges that with one stitch both edges may be transfixed at the same time. The knot of the suture should always be applied laterally from the wound. Su- tures should not be applied too tightly, as tension may produce irritation, necrosis, and abscesses in the stitch- holes. If there be any tension, however, It Is advisable to intertwist the ends of the thread twice, makino- a suro-Ical knot. The suturing should always begin at the middle of the wound, and not at its ends, especially in long wounds, as the edges may be adjusted much more easily if done in the former way. As a rule, about three stitches to the inch should be used. The needle should be introduced about a Fig. 49. — Interrupted suture. 1 66 SURGICAL ASEPSIS. quarter of an inch from the edge of the wound. If relaxation-sutures be required, they must be appHed first; in making them the needle should be introduced at least half an inch from the edees of the wound. In long wounds relaxation-sutures may serve as sitiiation-s2Uures — that is, they may answer the purpose of landmarks. Perfect ap- proximation is always of the greatest importance. If even a minute portion of the ^d^ O ASEPTIC OPEN-WOUND TREATMENT. 1 87 then be that if the pruiciples detailed in Section IX. on Aseptic Wounds, are observed, union by first intention may be obtained. Hence com- pound fractures with small wounds of the integ- ument — gunshot wounds, for instance — show a great tendency to heal if they are treated asep- tically — that is, if they are merely cleansed according to the principles of prophylactic disin- fection described in Section IV. A priori, it may be assumed that a bullet car- ries with it pathogenic microbes from the cloth- ing, etc. ; but clinical experience shows that infec- tion very rarely occurs in this way, provided the surgeon avoids severe manipulations, such as probing, incising, draining, etc., and simply fol- lows the principles of prophylactic disinfection. It may be that to some extent the heat of the bullet has something to do with the frequent aseptic course of gunshot wounds. During the Franco-German war (1870) Bern- hard von Langenbeck had the opportunity of observing at one time eleven cases of gunshot wounds in the knee-joint. According to the routine of that time, all patients were told that if they would not submit to amputation they must die. Ten consented to amputation, and died with the satisfaction of having been treated se- cundum artem ; but one patient, a stupid soldier who preferred death to amputation, recovered. I 88 SURGICAL ASEPSIS. Nowadays the real scientific question to be de- termined is whether or not any microbes can be discovered and cultivated, and if so, what spe- cies. The absence of microbes or the presence of innocent ones would require coaptation of the wound-edges, while the presence of virulent microbes would demand open-wound treatment. But this conclusion can be arrived at practically only under the conditions described in Section III., on the Means of Disinfection (see p. 88), and so the experience and ability of the surgeon must frequently govern the decision as to whether a solution of continuity shall be treated as an open or as a closed wound. A wound inflicted by a stone upon a labor-soiled hand has poor chances of union by first intention, therefore to seek to obtain such union would be useless. The principles governing the open treatment of wounds were followed long before the terms antisepsis and asepsis existed. It was well known that an irreenlar w^ound converted into a smooth- surface wound in which neither retention, decom- position, nor absorption of the wound-products is possible offers better chances for healing if treated by the open method than if it were oc- cluded. In 1806, Vincenz von Kern, an eminent Ger- man surgeon, recommended the open treatment of wounds {pansenient a del ouvert) as a method. ASEPTIC OPEN-WOUND TREATMENT. 1 89 He saw that it was likely to prevent putrefaction by keeping the edges of the wound well separated, thus giving free access of air and at the same time permitting escape of the discharges. His results were the most favorable known at that time. His method was employed especially after amputations, when, hemorrhage being thoroughly stopped, the entirely uncovered stump was laid upon a pillow so that the discharges could flow into a basin placed beneath. Healing took place by suppuration and granulation. The discharges always freely escaped, and consequently purulent absorption could not take place. In large and complicated cavities this method, unfortunately, was not so rigorously carried out, probably be- cause of the fear which prevailed in former years of making large incisions. An irregular cavity — that is, a cavity in which several wound-canals lead toward various parts of the tissues and end in small cavities that pre- sent superficial openings — would, if left uncov- ered, not answer the spirit of this method. True, the air would be able to enter, but it would not have access to all portions, nor could it circulate in the cavity. Superficial or temporary union of these deep-seated cavities might even entirely occlude them from the atmosphere. They would then become veritable hot-beds for the develop- ment of micro-orofanisms in the retained dis- I GO SURGICAL ASEPSIS. charges. Such cavities must be exposed as freely as possible, the pus must be allowed to escape, and the broken-down tissues must be removed. The question then arises as to the best manner of keeping open the exposed parts. Von Mosetiof-Moorhof devised a method which not only answers this purpose, but which at the same time also exerts a decided and permanent microbicidal influence upon the infected tissues. This method consists in methodical drainine" or in tamponing with iodoform gauze, the prepara- tion of which has been described on page 123. As shown in Section III. (p. ^;^), iodoform is not an antiseptic in the same sense as carbolic acid or bichloride. But undoubtedly iodoform ren- ders the products of the microbes in question harmless by forming with them innocuous com- binations. In organic tissue a decomposition of the iodoform takes place, nascent iodine probably being set free, during which process bactericidal effects are exerted. It is essential, after the preliminary conditions described above are fulfilled, that the gauze be brought into contact with every portion of the wound, as iodoform has no effect save by imme- diate contact. The packing should be done as loosely as possible, except when pressure is required to control hemorrhage. If rubber drainage is used, no antiseptic ASEPTIC OPEN-WOUND TREATMENT. I9I influence will be exercised upon the wound or the cavity itself; but when in a united wound the antiseptic gauze covers the outer ends of the tubes, it prevents decomposition of the wound-products only after they have left the tubes and have entered the gauze, so that the absorbent qualities of the gauze, which are of great value, are not utilized. If a cavity be packed thoroughly with gauze, every particle of discharge must be absorbed, and, however large the cavity, the pus will be in the gauze only, and the wound-surface cannot be otherwise than dry. A drainaofe-tube does not withdraw or absorb pus, for it has no power to aspirate the pus, which merely traverses the tube, its lumen being the point of least resistance. But the flow through the tube occurs only when pus is abundant, which is the first step to its retention. If the cavity be left open, the surgeon will be able to examine the field of operation, which ex- amination will be impossible when the wound is occluded. Laro^e incisions enable the surgeon to inspect as much of the tissue as possible, and it is almost as desirable to inspect suspicious wound-surfaces after operation as it is to do so during operation. Oftentimes tissues which at the time of operation were supposed to be of sufficient vitality, become later on gangrenous ; or in operations on tubercular joints or glands 192 SURGICAL ASEPSIS. tubercular tissue has been overlooked and left in sittc. It is little trouble to remove such diseased portions from an open wound later on, while if coaptation was the aim of the surgeon this valu- able feature would be relinquished. Amputation of a finger may illustrate the prin- ciples underlying open-wound treatment. Let it be assumed that a phalanx of a machinist's finger is crushed by a machine. The appearance of the fineer in this case will show considerable chancre, and the edges of the wound will be irregular. Bloody infiltration, blue or black discoloration, swelling, and irregular form of the finger are striking characteristics of the degree of de- struction. As the amount of infiltration of the tissues varies according to the amount of the force to which they have been subjected, extrav- asation may extend far beyond the wound. The edges of the wound as well as the deep-seated tissues may be so crushed that perfect necrosis has taken place. Bleeding may be stopped by the crushing, and sensation in the part may be lost entirely. Fasciae, tendons, and nerves may be crushed, and the phalanx may be reduced to a number of fragments. In this case conservative surgery is at a loss. The phalanx must be re- moved, not only because it is useless to the patient, but because it would also be an incu- bator for the development of microbes, proving ASEPTIC OPEN-WOUND TREATMENT. 1 93 of great danger for the hand, the arm, or even the Hfe of the injured man, as a wound of this kind cannot but be regarded as infected. After the necessary aseptic precautions (see Section X., on Infected Wounds) have been taken, the fingers and the hand are scrubbed thoroughly with a brush and soap. These pro- cedures follow the use of ether for removing any fatty and oily substances with which the clothing of the patient or the inflicting instrument — for in- stance, the wheels of a machine — may have been contaminated. Then alcohol and the bichloride are used, after the principles of prophylactic dis- infection (Section IV., p. 95). The whole arm must then be enveloped, and the entire vicinity of the injury be covered, with sterilized towels taken directly from a sterilizing apparatus. The necessary instruments — namely, knives, retract- ors, bone-cutting forceps, strong forceps to hold bone-fragments, tenacula and artery forceps, and dressing material — must be sterilized in the man- ner described in Section V. If, as may happen in private practice, a sterilizer is not available, the instruments, etc. may be made sterile in a common boiling-pot (see Section XVI. ; Fig. 63). If the tissues on both sides of the finger are fit for use, a double flap may be formed. The aggregate length of these flaps, which may con- sist of skin only, must be somewhat more than 13 194 SURGICAL ASEPSIS. the diameter of the finger at the level at which the bone is exsected or disarticulated, and only when amputation higher up is necessary is it advisable to leave some healthy muscular tissue in connection with the skin-flap. Such procedures are very much facilitated by the Esmarch method of constriction — that is, by firmly applying a rubber bandage from below upward, without reverses, to -just above the wrist. The rubber band is carried around the limb and is well stretched. After it is tied by its crossied ends or secured by its hook and chain, the rubber bandaofe which was carried around the limb may be released.-^ After removing all tissues whose vitality seems im- paired, and after bleeding is carefully arrested, the flaps are kept widely separated by iodoform gauze which is brought into close contact with each angle or pocket of the wound. A piece of sterilized moss or a voluminous mass of steril- ^ Previous to employing an Esmarch bandage the limb should be en- veloped with a sterilized towel or a bandage, which may be cut or lifted from the site of operation after the constricting bandage is taken off. It being somewhat difificult to keep rubber bandages sterile without impairing their usefulness, Neuber, Bardeleben, and other surgeons returned to the old method of Stromeyer, who used only strong linen bandages moist- ened before application. There can be no doubt tliat the marked ease with which linen bandages can be made and kept sterile, as well as their durability, is a great advantage. Their application, furthermore, is followed by far less parenchymatous hemorrhage, after the constriction is released, than occurs after the use of the ruljber bandage. Their main disadvantage is the greater care with which they must be applied. ASEPTIC OPEN-WOUND TREATMENT. 1 95 ized gauze must then be applied over the stump to absorb the sanguineo-serous discharge of the wound-surfaces. A spHnt of some kind should always be em- ployed. A long piece of moss-board merely dipped into, and not soaked in, sterilized water answers the purpose admirably, for if the dis- charges become abundant they will readily be absorbed by the moss splint without impairing its value as an immobilizing apparatus. The dressing should reach to the elbow. If the patient's condition remains normal and if no local symptoms supervene within forty- eight hours, the wound may be deemed in an aseptic state. The dressing must then be changed and the packing be withdrawn. If the surfaces appear clean and healthy, the flaps may be approximated accurately and be kept adjusted by carrying long strips of iodoform gauze around them. If coaptation is thus not sufficiently thorough to make the surfaces ad- here, the discharges may continue and imperfect union may result. But even in such a case retention can hardly take place, as the amount of pressure exerted by the surrounding gauze is so slight that the discharge easily finds its way out into the gauze. If there should, however, be any fear of retention, a small strip of gauze may be inserted into one angle of the wound. 196 SURGICAL ASEPSIS. In the great majority of cases union by first intention is still obtained in this way, and it should certainly be striven for if, on the change of the first dressing, an examination of the wound-surfaces shows healthy granulations. It is generally unnecessary to apply secondary su- tures in such cases. In wounds occluded imme- diately after operation, when they have become infected or distended by blood-clots reopening is imperative (see Section XII., on Renewal of Dressings) ; primary union, on the contrary, may still be secured, even if sutures are applied so late as three days after operation, provided the wound is then in an aseptic state. A patient suffering from an injury such as described might have recovered a few days ear- lier if sutures had been applied to his finger at the time of the operation ; but it cannot be denied that the risk of further infection is con- siderably lessened by the above-described open- wound treatment. The delay is decidedly pref- erable to the risk of infection on account of too thorough occlusion. The absorption of septic material will then not be arrested by reopening the wound, nor will a fatal course be stayed. Where cosmetic points come into question — in wounds upon the face, for instance — the prin- ciples of first and of secondary union may some- times be combined. The wound may be united ASEPTIC OPEN-WOUND TREATMENT. 1 97 partially, especially where the edges are easily approximated, and at different points between the stitches iodoform wicks may be introduced and be allowed to remain for two or three days, or until there is no doubt as to the aseptic state of the wound. If the wound-surfaces do not show healthy granulations — that is, if there are symptoms of infection — and if at the same time the general condition of the patient is impaired, the packing must be continued. The views on obligate and facultative anaerobes discussed in Section I. now find their practical application in our allowing free access of air — that is, of oxygen — to the wound. Knowledge of the biological peculiarities of pathogenic bacteria facilitates their destruction, or at all events aids in the prevention of their further multiplication. The more dangerous is the quality of the infectious element — that is, the more grave is putrefaction — the more strictly do the laws of anaerobiosis apply. The access of oxygen alone can do much more to destroy bac- teria than can oceans of bichloride. In putrid wounds no efforts at drying dis- charges should be made. The absorption of the discharges would be a grave error, inasmuch as they originate from a decomposed septic focus, and undoubtedly would become stagnant beneath 198 SURGICAL ASEPSIS. the dry dressing. In this position the discharges would prove merely a protection for the microbes, which would then be surrounded by their prod- ucts, the toxines. These toxines would form a kind of bulwark for the microbes, thus ren- dering them so much more resistant to disin- fecting procedures. Free access of air is best obtained by exten- sive incisions (even if they are only of an explor- atory character) into suspicious tissue and by radical and repeated excision of apparently necrotic portions. In such cases it is justi- fiable even to remove tissue not completely necrosed ; but when the appearance of the tis- sues (especially their discoloration, loss of firm- ness, etc.) manifests considerable impairment of vitality — as, for instance, in burns of the third degree — they must be removed without delay. Loose packing with gauze (preferably iodoform gauze), especially if the gauze is not fastened by a roller bandage, but remains in the wound- cavity uncompressed, does not interfere with cir- culation of the air in the exposed interstices. As clinical experience shows, moisture, while it should ordinarily be avoided in the treatment of wounds, is well borne in putrid zvound-cavities. Moisture can be applied by soaking the gauze introduced into the cavities with a weak solution of bichloride every hour; a i : 5000 solution ASEPTIC OPEN-WOUND TREATMENT. 199 generally proves strong enough for this purpose. If packing has been done, however, antiseptics must be applied to a cavity in a liquid form, to enable them, by permeating the gauze, to come into direct contact with the wound-surfaces and to exercise a permanent influence upon them. Sterile gauze can be used for this purpose as well as iodoform gauze, the latter being pre- ferred by the writer, as the influence of Iodoform is not impaired by its contact with the bichloride solution. While in aseptic wounds the dressing should be left undisturbed as long as possible, in infected wounds its renewal even two or three times a day would not be excessive. In surfaces of great extent, as in burns of the second and third degrees, weak antiseptics (sali- cylic or boric acid or acetate of aluminum) may be used. The least poisonous of these drugs is the acetate of aluminum: i to 2 per cent, of the drug in boiled water generally answers the purpose (see p. 81). These drugs are partially absorbed by the skin, and, although they cannot really disinfect an infected wound directly, yet in the course of time they exercise an indirect influence by diminishing the multiplication of the microbes. If bichloride be preferred, a strength of i : 1000 (later on, when healthy granulations appear, i : 2000 or I : 5000) will serve this purpose; but such disin- fecting influence is possible only when the main 2C0 SURGICAL ASEPSIS. requirements — namely, free incisions and free access of air — are fulfilled. IniniobiUzation is a strong adjunct in the treat- ment of all kinds of wounds. Therefore, if, as alluded to in the case of the infected fineer, the primary focus as well as its suspicious vicin- ity be exposed freely and loose packing be done, a splint reaching as far as the elbow should be adjusted, preferably at the side on which no incisions have been made. The most desirable support of this kind is a wire splint (Fig. 52), such as Kramer's, or the writer's modification of it. i ■ ■ : = = = - •- Fig. 52. — Simple wire splint. If this splint, after being boiled and loosely covered with sterilized gauze, is so adjusted by a gauze bandage that it encircles the ex- tremity without covering the wound-surfaces, it neither interferes with the principles of open- wound treatment nor impedes the action of anti- septic fomentation. The writer may venture to say that his modification of the Kramer wire splint allows much easier adaptation to the curves of the body than the original Kramer splint, consequently it can more advantageously be used to immobilize regions of irregular con- ASEPTIC OPEN-WOUND TREATMENT. 20I tour, such as the neck after an operation upon the cervical vertebrae. The treatment described above will often be followed by the conversion of putrid discharges — discolored, muddy, and of an offensive odor — into yellow, inodorous pus. After the mortified tissues, as well as those that have been injured seriously, are removed, there takes place a copious accumulation of migratory cells and a rapid multiplication of the fixed cells, in consequence of which there forms granulation-tissue containing cells and vessels in abundance. The surface of this kind of tissue is liquefied into so-called pics bonum ac laudabile. If removal of dead tissue be not accomplished by the surgeon, this process of liquefaction will separate the healthy from the necrosed tissue. The richer the vascularity the more rapid is the process of separation. (The spontaneous separation of dead fragments of fasciae, tendons, and bones would require considerable time.) As soon as the wound- surfaces are free of dead tissue, when the granulations are normal and the local symptoms as well as the general con- dition of the patient are satisfactory, the wound may again be treated on the previously described dry principles — that is, by packing it with iodo- form gauze and protecting it with a sterilized moss splint. This dressing usually does not require to be changed oftener than every sec- 202 SURGICAL ASEPSIS. ond or third day. By following the principles of open-wound treatment even malignant oedema, the bacillus of which is most virulent and very resistant, may be treated successfully. A short time ao^o the writer discharged from the surgical department of St. Mark's Hospital a patient who entered the institution seven weeks previously with the most alarming symptoms. The history of this man, aged thirty-five years, revealed that internal urethrotomy had been per- formed by an able surgeon who found the patient with an impermeable stricture. The operation was rapidly followed by the most intense reac- tion. The penis and the scrotum swelled to an enormous size within twenty-four hours, the pre- puce and a considerable portion of the pars pendula being black and blue ; the neighboring tissues emitted a fine crepitus when pressed by the finger, and the overlying cutis was raised into blebs filled with red and yellow serum. The patient presented a typical picture of great prostration and profound septicaemia. His almost constant apathy was interrupted by occasional delirious attacks. The pulse-rate was 146 and the temperature was 102.5° F. The tongue was dry. The emphysematous oedema and the ensu- ing gangrene naturally pointed to grave infection, to combat which required immediate and heroic means. In consideration of the very weak pulse ASEPTIC OPE h'- WOUND TREATMENT. 2C3 and of the apathetic condition of the patient no anaesthetic was given. Deep incisions were made, reachlnor from the anus across the scrotum, alonor- side the penis, and up to the left lumbar region. Within the extent of this whole area the cuticle was raised into blebs filled with sano^uinolent serum. The incised tissues were partially livid, partially gray and bluish-black, and were infil- trated with foul-smellinor, acrid secretions and with the gaseous products of decomposition. Everywhere underneath the emphysematous areas was found a gray-looking, dirty liquid mixed with gaseous bubbles. Simple incision and evacuation of these liquid elements would not have sufficed to destroy the soil for the microbes, inasmuch as the slouofhino- tissues, having been so long bathed in putrid fluid, were certainly more or less permeated with it. All the tissues the color of which had under- gone great change, especially the gray and black- ish-looking fascia and the connective tissue, were removed. A large sharp curette was at first employed for this purpose. After this manipu- lation, the finger being often employed to explore the pockets in. the deeper layers, the surfaces were wiped with gauze mops dipped in an 8 per cent, solution of chloride of zinc. Iodoform gauze loosely folded together was then Introduced. Bichloride (i : 20,000) was poured 204 SURGICAL ASEPSIS. into the gauze every hour to keep It continually well moistened. A considerable amount of ster- ilized gauze saturated with bichloride (i : looo) protected the packed wound-surfaces and their vicinity, thoroughly covering the scrotum, the penis, the upper region of both thighs, and the abdomen and the lumbar reofion on the diseased side. These fomentations of the i : looo bichlo- ride solution were reapplied every hour. There was no favorable change in the condi- tion of the patient during the following two days, but at all events the situation did not change for the worse. Above the right trochanter major a red spot, painful to the touch, was observed. An exploratory incision was made immediately after the discovery of this suspicious point. Deep under the fascia was found necrotic tissue bathed in a thin, brownish, putrid fluid. The whole area was treated in the same manner as was the field of the first operation. The following day the pulse fell to iio. It required about a week of repeated removal and elimination of necrotic tissues to convert the wound-surfaces into a region of normal orranulation. Dry treatment was then substituted for the moist fomentations — that is, the wound was packed with dry iodoform gauze and covered with sterilized moss. The dressing was changed once daily during the following week. Later on. ASEPTIC OPEN-WOUND TREATMENT. 205 when the discharges diminished, the dressings were renewed only every second or third day. At the time of the first operation cultures were made with the putrid secretions. After the cul- tures had been stained with fuchsin there were discovered numerous bacilli connected in a pecu- liar thread-like fashion, such as is characteristic of the bacilli of malignant oedema (see p. 44). As these micro-orcranisms are so-called " oblio^ate anaerobic bacilli," it is evident that any kind of occlusive treatment would only have favored their further development, while free access of the inhibiting oxygen of the atmosphere is their main destroying factor. Even if nothing but free incisions had been made and only the ne- crotic elements had been removed mechanically, it might have been possible to prevent further spreading of the malignant process. In reference to the use of the sJiarp spoon the writer may be allowed to call attention to its great usefulness, not only on account of its value in removing foul granulations, but also as regards its diagnostic merit. Healthy tissue cannot be scraped away if only the ordinary amount of force is employed. Thus the surgeon may form while scraping a more correct opinion of the vitality of the tissues than he would have been able to do before the foul orranulations were removed. Aponeuroses, fasciae, tendons, etc. 206 SURGICAL ASEPSIS. cannot, of course, be removed with the sharp spoon, forceps and scissors being required for this purpose. In tubercular processes the writer regards the open treatment as the ideal method. After re- section of a tubercular joint or after extirpation of tubercular glands suturing should only par- tially be performed, and then only in very large wounds. All the pockets, as a rule, should be loosely but well packed with iodoform gauze. The gauze may remain for five days after opera- tion if there be no particular indication for an earlier chano-e of the dressinor. It often occurs that the wound-surface of a tubercular area is covered by a layer of grayish granulating tissue. This tissue should repeat- edly be scraped until the surfaces show a tend- ency to heal — that is, until the pale, fungous granulations, manifesting no reparative tend- encies, have disappeared and the tissues have become firm and healthy. When, on account of local relapse, such repeated operations are required, strict aseptic precautions must be ob- served, precisely as at the first operation, as tubercular wounds are exceedingly susceptible to infection by pus-microbes. In the great majority of cases the further course of treatment demonstrates the peculiar antitubercular influence of iodoform, as wounds ASEPTIC OP EN- WOUND TREATMENT. 20/ treated with it generally heal in a satisfactory manner without forming fistulous tracts. Such influence can be obtained only if the iodoform remains in close contact with the exposed tis- sues. Further remarks on the antitubercular influence of iodoform are reserved for Section XIV., wherein Aseptic Injections will be dis- cussed. In laparotomies, especially in operations upon the intestines, drainage with iodoform gauze is of the utmost value. If, after resection of the intestine, the whole sutured area is well covered with two strips of iodoform gauze reaching to the mesentery on each side of the intestine, an excellent protection is secured ; consequently the sutures are not apt to cut through the edges of the wound, nor is it probable that perforation by a suture will take place. Discharge of feces into the abdominal cavity may thus nearly always be prevented ; should it really occur, however, the worst result would be a fecal fistula. The iodoform strips should be conducted through the abdominal wall to the external surface. The writer suggested^ fastening pro- phylactically with two fine sutures the point of the intestinal suture to the abdominal wall, 1 " Ueber die Behandlung gangranoser Hernien," Langenbeck's Archiv filr Chiriirgie, xxv. Bd., 1880, and " Resection of the Intestine in Gan- grenous Hernia," N. V, Med. Record, April 8, 1893. 208 SURGICAL ASEPSIS. thus enablinor the suroreon to find the suturinor point easily in case symptoms of separation should appear and the formation of a fecal fistula should no longer be avoidable. This method does not disturb the healing process, which fact cannot be said of the knot proposed by Jobert. As W. Rindfleisch has shown by experiments on animals, a sutured intestine generally remains exactly at that point of the abdominal wound where it has been placed. On the basis of this observation he claims that prophylactic sutures are unnecessary. However this may be, the writer deems it safe to use them. They cer- tainly facilitate the search for the suturing point if secondary operations should be necessary. In cases of operations on the liver or the gall- bladder the strip of iodoform gauze can seldom be dispensed with. It has the great advantage of absorbing blood, which generally oozes in con- siderable quantity from wounds inflicted upon these oro-ans. In this event the adhesiveness of iodoform gauze proves of great value, as it adheres to the bleeding surface of the liver, thus preventing hemorrhage into the peritoneal cav- ity. The gauze may be left in the cavity for from one to two weeks, and as soon as it is ex- tracted rapid occlusion ordinarily takes place, so that the healing process does not require much longer than if primary union had been obtained. ASEPTIC OPEN- WOUND TREATMENT. 209 The iodoform-gauze strip should be very long, so diat only a single piece will be required. It may be folded together and be pressed against the parenchyma. A small end of the strip may then be led through an interspace left between the sutures of the abdominal wall. In excep- tional cases it may be impossible to attach the gauze tightly ; it may then be fastened to the parenchyma with a few fine sutures applied to the capsule. As iodoform gauze adapts itself tightly to the serosa, it becomes loosened only when the discharges grow copious. The writer has sometimes kept 10 per cent, iodoform gauze in the abdomen for two weeks, at the expiration of which time it still con- tained plenty of iodoform, and bacterioloo^ical inves- tigations proved it to have remained sterile. Mikulicz advised the use of iodoform gauze in the shape of a gauze bag (Fi^- 53) ^s a very effi- cient means of abdominal drainaore. The bae should be at least one inch wide and from six to ten inches lono-- The bao-, filled with a few strips of iodoform gauze, of a width of Fig. 53. — Mikulicz's bag: a, abdominal sutures ; b, gauze bag ; c, abdominal wound ; d, loops in tlie abdominal wall ; e, gauze strip. 14 210 Si'KGICAL ASEPSIS. about two inches, or with iodoform wicks, should have a string tied to its lower end. After an ope- ration on the pelvic organs the bag is placed in the pelvis, across that part requiring drainage ; it is then carried over the fundus uteri and led toward the outside of the abdomen, between the sutures in the abdominal wall. The abdom- inal opening can be separated widely by pulling on loops conducted through each edge of the abdominal wound. Capillary attraction brings the secretion to the surface, where it is absorbed by a thick layer of gauze or, preferably, by ster- ilized moss-board, the latter at the same time acting as an immobilizing agent (see p. 122, Fig. 34). The strips or the wicks may be removed gradually — that is, some on the day following the operation, and the others a few days later, as the case may require. Wicks are always to be preferred on account of their greater power of absorption. At last the bag itself may be re- moved by making traction upon the string fast- ened to the bottom. The crreat advantage of this method over drainage by rubber and glass tubes is its continuous and automatic action as well as its non-irritation. Ordinary hard drain- age-tubes would irritate the intestines, the ends of glass tubes especially exercising great pressure. Hemorrhage from the large venous sinuses of the brain can seldom be stopped except by packing ASEPTIC OPEN-WOUND TREATMENT. 211 the bleeding surfaces with iodoform gauze, which must remain in situ for at least one week before firm union of the walls of the sinuses takes place. In operations upon the kidneys the iodoform- gauze tampon prevents retention of discharges in the retro-peritoneal space, the anatomical con- dition of which favors burrowlnof of the dis- charges, an occurrence which in this particular region would nearly always lead to a fatal result. In areas such as the i^ectiim, wher^ the tissues may be contaminated by the constant Inundation of infectious material, the iodoform tampon offers the best kind of protection. What, indeed, would surgeons do to cover the wound-surfaces after a resection of the rectum, of the superior maxilla, or of the tongue, without the lodoform-gauze tampon ? Methodical temporary packing with iodoform gauze may be performed In all cases of par- enchymatous hemorrhage. After resections, in which considerable oozing from the bone-tissues generally takes place during the twenty-four hours following operation, the gauze stops hem- orrhage until the capillary vessels are spontane- ously occluded by coagulation. Twenty-four to forty- eight hours after such operations, if no evi- dence of hemorrhage is present and if the wound- surfaces appear normal, the gauze may be re- moved and the surfaces may be coaptated either 212 SURGICAL ASEPSIS. by winding iodoform-gauze strips around them (see p. 195), If the edges of the wound can thus be approximated, or by applying secondary su- tures. Iodoform wicks may be used instead of the gauze, on account of their greater power of absorption, just as in peritoneal drainage. Tem- porary packing with iodoform gauze very often stops hemorrhage from parenchymatous surfaces much more efficaciously than does the Pacquelin cautery. Gauze mops pressed tightly for several minutes against the bleeding surface in operations on parenchymatous surfaces like even that of the liver (compare p. 207) generally arrest the hem- orrhage entirely. RiMer drainage-tubes [cov^"^. pp. 1 39, 1 90) should be used only when the employment of gauze is impossible. This is especially the case in large cavities to which free access is impossible or is very difficult, as in pyothorax, for instance (see p. 234). Here the surgeon has to deal with a large cavity the free exposure of which would require such extensive operation as seriously to endanger the patient's life. Were this not the case, thorough packing of the cavity with iodo- form gauze would be the proper treatment. Therefore other than the usual means of pre- venting retention of pus must be employed. To this end the patient should always lie on the dis- eased side of the thorax, and about every four ASEPTIC OPEN-WOUND TREATMENT. 213 hours should be Hfted by the feet to compel the pus to flow into the dressing. At a superficial glance this advice may appear rather strange, but clinical experience shows that the observ- ance of this procedure is apt to prevent reten- tion, and it is needless to urge the importance of never allowing stagnation of pus on. a wound- surface or, especially, in a cavity. Thus counter- openings, as advised by Kuester, may be avoided. If such cavities are kept wide open, the introduc- tion of a dilating speculum such as advised by the writer is easy and allows free inspection of them. The writer has refrained from introducing a rubber drainage-tube into the pleural cavity im- mediately after resection of a rib in pyothorax, as he has witnessed considerable bleedino- in consequence. Moreover, the constant respiratory movements of the pleura cause irritation by fric- tion. Therefore, three days after operation the writer introduces a rubber drain, of at least the size of a man's finger, secured by two large safety-pins adjusted in the shape of a cross. It seems that after the pleurae become accustomed to contact with the atmosphere, and as soon as granulations appear, they bear the irritation well. Two weeks after operation, on an average, a small drain is introduced and is gradually short- 214 SURGICAL ASEPSIS. ened. When the discharges become scanty the drainage-tube may be left out and a small strip of iodoform gauze may be substituted. Similar principles should govern the intro- duction of rubber drains after perineal or supra- pubic section. Posture is also very important in such cases. The patient must lie in a position such as will easily allow of spontaneous discharge of the urine. If a rubber drain must be used, it should be surrounded with iodoform gauze when- ever this is possible. This procedure applies especially to infected cavities, such as a bladder which for months has been occupied by a stone bathed in purulent urine, and which cannot be rendered aseptic in a few minutes after the stone has been extracted (see p. 98). In such a case the combination of iodoform gauze and a rubber drain proves especially valuable. XII. RENEWAL OF DRESSINGS. The ideal toward which the modern surgeon strives is primary union ; consequently he ex- pects either no discharge in the wounds he makes or only such a small amount of discharge as will not interfere with healing under a single dress- ing. The less frequendy the dressings are changed, the more agreeable it is to the patient. Even the gentlest renewal cannot but cause ' RENEWAL OF DRESSINGS. 215 some pain and no inconsiderable possibility of secondary infection. The main indications for chanore of dressinor are : (i) When stitches or drainage-tubes require removal ; (2) when secondary hemorrhage oc- curs ; (3) when discharges become so abundant that they cannot be absorbed by the dressings, consequently transuding to the surface ; (4) when the dressing is so disturbed that either the pro- tection of the wound becomes imperfect or there is risk of contamination by urine, feces, etc. ; (5) when the patient complains of considerable pain ; (6) when fever sets -in and general symptoms point toward infection ; and (7) when there is any doubt as to the character of the fever. In these events clinical experience seldom fails to guide the surgeon properly. In the majority of cases removal of the stitches should take place between the third and seventh days, according to the character of the wound. After delicate plastic operations on the face a few sutures may be removed as early as twenty-four hours after operation, while in other operations — for instance, after laparotomy — the sutures should remain in situ for at least one week — as a rule, from ten to fourteen days. In very long ivounds, or in those where there is danger of sloughing after removal of the sutures, the stitches should be taken out gradually — that is, 2l6 SURGICAL ASEPSIS. only a few sutures at the place of least tension should be removed at intervals of several days. Manifestly, when rclaxatioii-siitures are used in connection with continuous sutures the inter- rupted relaxation-sutures must be taken out first. Whenever such sutures cut through the skin they must immediately be removed. Removal of interrupted sutures is performed by seizing one end of the knot with a dissecting forceps and, while slightly drawing upon the knot, cutting through the loop laterally from the line of incision with narrow-bladed scissors. The suture may then be drawn out slowly. It may easily occur that an overlooked particle of the suture remains. This accident should care- fully be avoided. Continuous sutures can much more easily be removed by simply drawing them out after cut- . ting through the exposed por- tions between the stitch-canals. The knot (Fig. 54) should always be conducted above the line of incision, so as to prevent separation of the wound-edges, Fig. 54. — Extraction i • i • • i -i ' of suture which separation might easily oc- cur if the knot were drawn out toward the opposite side. If tension threatens to separate the lips of the wound, a portion of the sutures should be left in place until the next RENEWAL OF DRESSINGS. 21/ removal, when they must be examined thor- oughly. If some tension ts still present, the sutures may be left until a subsequent change of dressing, otherwise they may be extracted at once. If catgut be used, these procedures are unnecessary, as that part of the suture imbedded in the tissues will be absorbed, so that only the portion of the suture remaining on the surface need be lifted from the skin with forceps. After removinof the sutures the wound should be covered with sterilized gauze. Wiping or press- ing the wound, irrigation, or other manipulation should be avoided. The modern suro^eon is characterized by doing little on the aseptic wound itself, and much around it. A clean wound healing by first intention should never show the slightest reaction. The edges should be neither reddened nor swollen, nor should any infiltration be present. No pain is ever associated with a wound thus healed. Alonor the line of union as well as alonorside the sutures dried blood and serum are all that will be found. The inner layer only of the gauze protectinor the wound-surface should contain i O a small amount of odorless and dried serum. The first layer of gauze — that is, the one put immediately upon the united wound — may be protected by a second layer of gauze, or, prefer- ably, by sterilized moss-board, which has the 2l8 SURGICAL ASEPSIS. advantage of supporting and immobilizing the parts. The secondary dressing of a wound healed by first intention should be completed over a smaller area than the first dressing, and it should be ap- plied in the same manner as is done immediately after operation, since hardly any further dis- charge is to be expected. Four or five days later the dressing may again be removed. Such sutures as were left at the time of the latest removal may then be taken out. If the sutures have been removed completely at the first re- newal of dressing, there will remain only a nar- row line indicatincr the incision. The dressinor may then be dispensed with entirely, or, in case there is found some excoriation of the stitch- canals or of the vicinity of the wound, there may be applied a non-irritating adhesive such as the yellow adhesive plaster. Wounds which were united, but into the cor- ners of which small drainaoe-tubes had been inserted, present about the same appearance as those which were sewed up entirely. After ope- rations, as amputatio mammae, in which buried sutures alone do not suffice to prevent the formation of pockets (possibly beneath the la- tissimus dorsi and on the anterior surface of the thorax), drainage must be employed. This is best effected by the introduction of gauze RENEWAL OF DRESSINGS. 219 draijts, but some surgeons prefer very small rubber drains, which must be removed at the first renewal of the dressing. Sterilized-gauze mops should then be kept in readiness to wipe off the serous discharge from the small openings. Wounds of this kind should present as little irri- tation as those previously described, from which they differ only in discharging more copiously into the gauze. But this discharge has gener- ally dried at the time of the first re-dressing. Sometimes even the gauze drain is dry, or is but slightly moistened with a sero-sanguinolent discharge. In the absence of infection the wound-canals formed by the drain will be found free of pus, although they may be filled with granulations. After having removed the gauze drain it is ad- visable to introduce a smaller one, provided the discharge is scanty. Instead of removing the gauze strip, it may be pulled out to a slight extent and be shortened with scissors at the time of the first renewal, and be removed en- tirely at the second change of the dressing. The same principles apply when, exceptionally, rubber drainage is used. A gauze drain, when introduced too tightly, is sometimes apt to occlude the canal entirely, thus causing the very retention it is desired to prevent, or, if there are several sinuses, one 220 SURGICAL ASEPSIS. or the other may close spontaneously, thereby retainhig the fluid wound-products. Mild symp- toms of retention then frequently supervene ; when they occur, immediate removal of the gauze is indicated. In such a case, as soon as the gauze drain is drawn out with the forceps the retained discharge generally follows. If this should not occur, careful palpation will often in- dicate the seat of retention, toward which a thin forceps should then be guided to separate the adhesions and to permit the free discharge of the retained fluid. The wound should then be repacked loosely. Occasionally a rubber drain surrounded by gauze may be employed satisfac- torily, but only for a few days, as it is expected that after the discharge has lessened the gauze may be substituted again. In removing sutures in such cases procedures are in order similar to those advised in com- pletely united wounds. Seco7tdaiy hemorrhage is another indication for removing the dressing. In wounds which were sewed up entirely secondary hemorrhage is gen- erally due to lack of thoroughness in ligating the vessels, but it may be caused also by the coming away of a ligature due to some move- ment of the wounded part, or in exceptional cases by the action of the heart in driving out coagula from the end of a divided vessel. RENEWAL OF DRESSINGS. 221 In open wounds hemorrhage may be caused by disease of the walls of a vessel or by slough- ing or ulceration or septic infection of the wound. Too rapid absorption of catgut ligatures also fur- nishes a quite frequent source of parenchyma- tous or capillary hemorrhage. It may also be caused by persistent bleeding which during ope- ration was arrested only temporarily and super- ficially by tamponing. In large, deep cavities it may be impossible to apply ligatures to a bleeding artery. Atheroma- tosis may also render the vessel so brittle that the ligatures cut through instead of constricting it. Exceptionally there may be other reasons that compel the surgeon to resort to the gauze tampon. The dressing must then be applied very tightly, and, if necessary, it may be sup- ported by marine sponges. Naturally, when such conditions are observed during operation, the surgeon should be prepared for secondary hemorrhage after the close of the operation. Hemorrhage may, however, set in without any perceptible cause, or it may be caused by any- thing that is likely to increase pressure on the circulation — that is, by coughing, by strangling, or by any other violent effort. It is thus evident that dressings applied under these circumstances, especially to the posterior and most dependent parts of wounds, must be watched with the 222 SURGICAL ASEPSIS. Utmost care, and after the dressing has been re- moved a new layer of gauze must be pressed tightly against the wound-surfaces. If this pro- cedure does not prove successful, the gauze tam- pons introduced immediately after operation must be removed. New strips must now be in- troduced with a dressing-forceps, by which the gauze can be forced in much more tightly than by any other instrument. Should blood flow freely from the wound, the sutures must be cut through and the edges of the wound be separated instandy. If hemorrhage takes place from an extremity, an Esmarch band- age or some variety of tourniquet should at once be applied (see p. 194). This compression will materially facilitate the procedures afterward to be carried out. The clots filling the cavity are turned out rapidly by wiping the surfaces with gauze mops, so that a clear view of the region may be obtained. If the wound is not too deep nor too irregular, the source of the hemorrhage will soon be discovered. If the source of the hemorrhage be a vessel, it must be tied. If its brittleness or its close attachment to a bone, or any other reason, renders impossible the encir- cling of the vessel with a ligature, it must be caught up by an artery-forceps, which may be left ill situ. The wound must then be kept well open and be dressed in this condition. Thor- RENEWAL OF DRESSINGS. 223 ough packing with gauze is often successful after failure to control the bleeding by the above methods or after having passed sutures under the tissues containingr the vessel. After laparotomy hemorrhage will only excep- tionally be discovered at its onset ; consequently the chances for reopening the abdominal cavity are very unfavorable, as the patient will have lost a great amount of blood before the symptoms of internal hemorrhage are well developed. Drainage after laparotomy reveals secondary hemorrhage much more readily and earlier than in cases in which it is omitted. The blood-satu- ration of the gauze, however, is not necessarily an index of the amount of blood being lost; this is indicated better by the constitutional symp- toms, which will be the same as those of any other concealed hemorrhage ; their gravity will decide the question as regards reopening the abdomen. A very frequent indication for the renewal of dressings is that in which the discharges are so abundant as to inhibit further absorption. As a rule, after operation on large cavities, where the edges can be united only partially or where the surgeon is compelled to leave the wound entirely open, according to the principles described in the preceding section, a considerable amount of dis- charge must be expected. The first dressing 224 SURGICAL ASEPSIS. must then be chano^ed In two to four davs. In such cases, on removing the dressnig its outer layers are partially saturated with an odorless and sanguinolent discharge, while the inner layers contain an abundant discharge. The gauze situ- ated directly upon the wound-surfaces generally contains purulent fluid in addition to the sero- sanguinolent liquid. In that portion of the wound united by sutures such perfect primary union may have been ob- tained that the sutures may safely be taken out. The gauze, if saturated with the sero-sanguino- lent or the suppurative discharge, may then be drawn out with a dressing-forceps, and either be shortened or, if the discharge is abundant, be re- moved altogether and fresh gauze be substituted. If the principles described in Section XL, on Open-wound Treatment, especially in reference to gauze packing, or to thorough removal of necrotic tissue, were not rigidly observed, it may occur that by drawing the gauze strips forward some retained fluid will be evacuated. This fluid may be mopped into sterilized pus-basins or be taken up by pieces of gauze surrounding the margins of the wound. After having the whole field wiped clean of dis- charges another dressing should be applied ex- actly as that directed after an operation. After the lapse of from three to six days the dressing RENEWAL OF DRESSINGS. 225 must again be renewed if the amount of dis- charge is sufficiently great to require renewal. Decrease of the discharge, which will then have lost its sero-sanguinolent character and have be- come entirely purulent, may be expected. The wound-cavities will generally have become much smaller by this time, as they are being filled by granulations exactly as in superficial wounds of the skin. At the second change of the dressings on wounds producing abundant discharge there may be removed all the sutures not taken out at the first removal. A strip of iodoform gauze, smaller than the one used at first, may be intro- duced loosely into, and be kept in, the cavity, which may be in the same condition now as a common aseptic wound, described above, so that, consequently, it can be treated after the same principles — that is, at intervals of from three to six days the same operation may be repeated until the cavity is occluded by granulations. If during the after-treatment no micro-organ- isms have entered the wound-cavity, the discharge becomes serous and scanty and the wound-sur- faces are glued together at all the coaptated points. Where no such agglutination takes place granu- lation tissue will be produced until the cavity is entirely filled with it. Suppuration does not necessarily take place under such conditions, 15 226 SURGICAL ASEPSIS. hence this manner of heaHng by second intention does not differ materially from direct union by first intention. As a matter of experiment, in resection of a tuberculous knee-joint the writer, after thoroughly packing all cavities with iodo- form gauze and after surrounding the whole leg with a large piece of sterilized moss, left the dressing undisturbed for three weeks. After the lapse of this period of time a slight, somewhat odorous discharge was observed on the outer surface of the dressing. When the latter was removed the wound appeared perfecdy normal. No microbes could be cultivated from the gauze covering the wound-surface, and no smell except that of iodoform could be detected in this por- tion of the dressing. Dressings occasionally produce dermatoses. Thus, eczema may result from retained perspi- ration or from the irritant influence of antisep- tics. These eruptions naturally make renewal of the dressings obligatory. The first of the above-mentioned causes may give rise to simple dermadds, which renders imperative a change of dressing and appropriate local treatment. In- tense irritadon of the skin may result from employing as a fomentadon bichloride of mer- cury, in which event the substitution of another andseptic is indicated. Iodoform (see p. 86) may also produce eczema, RENEWAL OF DRESSINGS. 22/ especially in individuals who have a peculiar predisposition to this form of dermatitis. The writer's experience at the German Polikinik in New York City shows that about two patients in each hundred are likely to acquire eczema from the use of iodoform. If such patients are care- fully watched the eczema seldom acquires such headway that it cannot easily be checked by merely discontinuing the iodoform and substi- tuting sterilized gauze. The writer commonly uses salicylated gauze until the eczema is healed. The main symptoms indicating the formation of eczema tmder a dressing are burning and itch- ing sensations, which may be so intense that the patient cannot resist the temptation to scratch the part even through the most carefully-ad- justed dressing. Manifestly, this act is likely to interfere seriously with asepsis, and it is ample indication for the immediate change of such dressings. It seems to the writer that most cases of iodo- form eczema are generally unrecognized at their earliest stage— a deplorable fact that may lead to serious complications. The text-books do not materially aid in forming a judgment of these eruptions, which, although they generally are of an erythematous character, may assume the pap- ular and urticarial as well as the petechial form, or which may even develop vesicles. The der- 228 SURGICAL ASEPSIS. matitis at first is confined to the site of the appHcation of the iodoform, but it may ultimately spread over the whole body. Most patients acquire eczema only after iodo- form has been used for several days or even for weeks. In the case, for instance, of a little boy whose great toe was crushed by an elevator, the attending physician removed the bone-fragments at once and dressed the wound with iodoform powder and gauze. The patient did well for five weeks under this treatment, and the wound had nearly healed, when suddenly the toe and its adjacent parts became red, swollen, and painful. The physician told the parents of the boy that for some unknown reason trouble had arisen in the bone. He thouo^ht his treatment had not been sufficiently antiseptic, and he tried to correct this supposed deficiency by applying a quantity of iodoform powder greater than before. Conse- quently, on the day following the application the whole foot was extensively swollen. The physi- cian thought that he still had not done enoucrh iodoformization, and he then anointed the whole extremity with iodoform vaseline. When, after this last application, the process became diffused over the leg, vesicles appeared, and pain in the groin indicated swelling of the inguinal glands, the physician became frightened and suggested amputation of the toe. This advice, fortunately, RENEWAL OF DRESSINGS. 229 was not followed, but another physician was called in, with whom the writer saw the case in consultation. It caused the writer some trouble to convince his colleague that there was neither an inflammatory process in the bone nor erysip- elas, but that the erythematous eruption and the little vesicles were due to the iodoform. The whole treatment for the following three days consisted simply in doing away with the drug, and perfect recovery followed within a few days. Some cases, moreover, quickly show a most decided and rapidly-spreading eruption, even after minimal quantities only are applied. This rare type the writer used to term the "foudroy- ant." In cases of this kind the dermatitis may spread over the whole body within a few hours, and it must then be considered quite serious. Laborers, machinists, etc., whenever injured, should be asked, before applying an iodoform dressing, whether previous injuries were followed by eczema in consequence of using the "yellow powder of offensive odor." The writer can recall a number of individuals — laborers, machinists, etc., who, on account of the dangerous nature of their business, are exposed to repeated injury — who are aware of their susceptibility to iodoform, and who have acquired such a dread of iodoform eczema that after an accident they implore the surgeon not 230 SURGICAL ASEPSIS. to use iodoform in dressing die wound. This idiosyncrasy is sometimes developed to an extra- ordinary extent. The writer knows of several physicians who are apt to acquire an eczema from merely touching iodoform gauze. If the dermatitis is so intense that oedema, infiltration, pain, and fever appear, a differen- tiation from septic erythema or from erysipelas may be difficult. In such a case it should espe- cially be remembered that in erysipelas the mar- gins of the vesicles are wall-like elevations. Necrosis of the margins of the wound may set in when they are insufficiently nourished in con- sequence of the cutting off of their blood-supply. (Compare Section XL, on Open-wound Treat- ment, p. 183.) Such an occurrence is apt to result after plastic operations, amputations, etc., espe- cially if the base of the skin-flap is too narrow or if the sutures are applied so tightly that circula- tion is impaired by pressure. Diabetes particu- larly favors this condition. In such a case the sutures must be taken out and the necrotic por- tions of the wound must be removed. If for any reason the suspicious-looking portions cannot be removed, they should at least be dusted with iodoform or be surrounded by iodoform gauze, which has no disinfectin^r influence in itself, but which represents a protection apt to prevent further infection of the adjacent wound-surfaces. RENEWAL OF DRESSINGS. 23 1 Necrotic wound-surfaces are best treated ac- cording to the principles enunciated in Section X., on Infected Wounds (p. 172), and no oc- clusive dressing should be applied. Iodoform gauze is introduced loosely into the cavities and is renewed at least once a day. While, as a gen- eral principle, dressings should be changed as rarely as possible, in regard to necrotic wound- surfaces the opposite view must be taken until they have assumed a healthy condition. A few words regarding suhires may here ap- propriately be added. If the sutures have cut throuofh the skin so that the wound slouorhs, they must be removed entirely. It then becomes a matter of choice either to let the wound-cavity heal by granulation or to unite it again by sec- ondary sutures after freshening the surfaces ; this latter procedure, however, will only exception- ally be successful. It is only after operations for hare-lip (where partial sloughing is of quite frequent occurrence) that such secondary sutures have rendered the writer valuable service. Silk or catgut sutures which have not been sterilized thoroughly are not infrequently the sources of infection followed by suppuration in the stitch-canals. Cuttino- throuorh the sutures favors suppuration, which may take place super- ficially as well as in the bottom of the cavity when buried sutures are used. If suppuration 232 SURGICAL ASEPSIS. is only superficial, the pus may escape sponta- neously through the stitch-canals, and conse- quently the general condition of the patient need not necessarily be impaired. Deep-seated sup- purating sutures naturally cause great disturb- ance of the general condition of the patient, such as fever (up to 103° F.), violent pain, loss of appetite, etc. If the dressing is changed, the tissues will be found reddened and will show extensive infiltration. Collateral oedema is sel- dom absent, in which case dilatation of tlie wound-canal with the forceps, or incision, is called for to allow the pus to escape. If there is much dischm^ge, the dressing should be changed at least once a day. If much inflafn- mation be present, antiseptic fomentations (pref- erably of the acetate of aluminum) should be used, after loosely packing the cavities with iodoform gauze, until the inflammatory symp- toms have subsided ; a dry dressing may then be employed. Sometimes granulations form so abundantly as to require their removal with a sharp curette. If stasis In circulation takes place, the granu- lations assume a dark-red or a bluish appear- ance and finally break down into foul ulcers. This result occurs especially in varicose ulcers of the leg, where, Instead of normal red granula- tions, there Is found a gray surface covered with RENEWAL OF DRESSINGS. 233 debris and necrotic tissue. Naturally, there is no tendency to the formation of skin-tissue until this more or less infectious material is all removed by scraping and until firm and healthy tissue is reached. The writer found it useful to apply an 8 per cent, chloride-of-zinc solution to such surfaces after curetting. (Compare Section III., on Means of Disinfection, p. 68.) The writer generally applies either iodoform or sterilized eauze to the surface after the bleed- ing has been stopped by pressure, the gauze being protected with a large piece of dry steril- ized moss secured by a gauze bandage. The dressino- is then drenched with a weak solution of bichloride or of acetate of aluminum to make the moss swell, by which means continuous press- ure is exerted upon the ulcer; this pressure is sustained by saturating the moss with the liquid every few hours. Pressure in itself being a decided and well-known healing factor, it can thus advantageously be combined with such antiseptic fomentation. If the extremity is not entirely encircled by the moss, the circulation does not become endan- gered. When the ulcerated groove begins to fill and the discharge grows scanty an ordinary adhesive plaster and a compressive bandage may be substituted. The same principles of treat- ment may be followed out at other points, as 234 SURGICAL ASEPSIS. well as in similar conditions — for instance, in tuberculous or specific ulcers. As a rule, such dressings should be performed daily until the granulations assume a healthy appearance. Tuberculous as well as specific ulcers must be scraped repeatedly, and until a satisfactory state is obtained the dressings should be renewed frequently, at least for inspection. Of course, in such cases constitutional treatment should be employed at the same time. If rubber drains are used in large cavities, the tube should gradually be shortened. In cases where — as in pyothorax, for instance (see p. 212) — resection of a rib has been performed, a drainage-tube smaller than the one first used is generally required two weeks after operation ; after another week this tube also must be shortened. When the dis- charge becomes at last serous and scanty the tube may be dispensed with and a small strip of iodoform gauze or a wick be substituted for a day or two. For the next few days the patient must be watched very carefully. The cavity may be ob- literated after twenty-four hours, but very often the union is only superficial, and there occurs retention of pus, which is manifested by an ele- vation of temperature. The drainage-tube must now be re-introduced, and after a week the short- ening of the drainage-tube must be repeated RENEWAL OF DRESSINGS. 235 until, four days after the obliteration of the pus- cavity, no discharge appears and the temperature remains normal. In doubtful cases the grooved director may reveal the presence of retained pus. The dresslnor of such larcre cavities must be changed about twice a day for the first week, later on once a day, and after three weeks it wnll suffice to change the dressing every second, third, or fourth day. As has been shown, the open-wound treatment is the treatment par excellence for compound frac- tures. In cases where much displacement is present frequent change of dressing is Indicated, to permit repeated inspection of the bone-frag- ments, which, should they be displaced again, may thus easily be returned to their proper places. For cases in which union fails to take place the writer has devised a canaliculated metal splint whose concavity fits the convexity of the bone- fragments, upon which the splint is fastened with a few screws (Fig. 55). This metal splint when in situ embraces the bones to the extent of three-quarters of their periphery, and must then be protected on Its exterior surface with iodoform gauze, which must be renewed about once a week. Four weeks after the splint has been screwed on, when at least superficial consolidation may be expected, 236 SURGICAL ASEPSIS. an effort to extract the splint is made. If the opening has been kept widely separated by the gauze, the extraction will be easy. When pain is complained of there must be somethine wrons: in the wound, which then re- quires renewal of the dressing, at all events for exploratory pur- poses. The thermometer Is often a good guide in treatment. Ele- vation of tempei'ature demands immediate change of the dress- ings. Shortly after the removal of the dressing from suppurating wounds a sliorht elevation of tem- perature usually results as the „ , . natural expression of the irrita- FlG. 55. — Posterior ^ ^ view of Beck's ex- tion of the wound. Therefore, if tractable bone-splint ^q constitutional disturbance of any kind be observed, this symp- tom would be no indication to renew the dressing before the third or fourth day after operation. The principles of prophylactic disinfection described in Section IV. must be observed when a dressing is renewed, and the preparations should be identical with those made for an ope- ration. Before touching the dressing's the hands must be disinfected thoroughly. A nurse should cut through the bandages and the superficial RENEWAL OF DRESSINGS. 237 layers of the gauze with the bandage-scissors. The surgeon, using steriUzed forceps, then raises the gauze directly overlying the wound. It is inexcusable for a surgeon to follow asep- sis half-heartedly or to omit precautions on the score of these being unnecessary, even though a wound be septic. If the hands are not disin- fected, they may carry pathogenic microbes of greater virulence than those with which the wound was originally infected. All re-dressing should be done with sterilized instruments, the hands being always kept asep- tic. Whenever the hands become contaminated, they must again be disinfected as thoroughly as before. The whole vicinity of the wound should be protected with sterilized towels after the part surrounded by the dressing has been well ex- posed. In hospitals the removal of the dressing should be done in a separate room suited to this particu- lar purpose, whenever the condition of the patient will allow him to be transferred. In the surgical ward of a hospital it is convenient to keep patients that require dressings separate from the others. For instance, a laparotomy case should not, as a rule, be contiguous to a case of subcutaneous fracture. It is always advisable to attend aseptic cases before dressing or treat- ing suppurating and infected ones. 238 SURGICAL ASEPSIS. When the writer enters the suroical ward of the hospital the first act of the nurse in charge is to prepare boiHng water for the small ward sterilizer. While attention is being given to patients not suffering from wounds such as frac- tures, dislocations, inflammatory processes, etc., preparations are being made for the renewal of the dressings of patients who cannot be trans- ferred to the separate room. The instruments are sterilized at the same time, and are taken directly from the apparatus after the assistants, the nurses, and the writer have disinfected their hands according to the principles of prophylactic disinfection. After use the instruments are replaced in the sterilizer. While an assistant finishes the bandaging the writer again disin- fects his hands precisely as before, and the house- staff are required to do likewise. The instruments are again taken from the sterilizer, and another patient's dressings are renewed in the same manner. There is no excuse for not observing the same precautions in dispensary and in private practice. In the surgical department of a dispensary the work is greatly facilitated by separating patients with traumatisms from the other patients, and by dressinpf the former after the latter have been attended to. After a dressing has been removed the instruments used for its renewal are put for TECHNIQUE OF AN ASEPTIC OPERATION. 239 two minutes into boiling soda-solution. They are then taken out by long, sterilized forceps and put into the basin containing the aseptic instru- ments in sterilized water. This basin was termed by the writer "the sanctum," in order to guard against mistakes on the part of young assistants and nurses in the different designations of the aseptic arrangements. Whatever instrument has been handled must be boiled in the sterilizer before it is regarded worthy of a place among the instruments in this aseptic basin. After each re-dressing the hands must again be disinfected before making another new dressino-. At first the above-mentioned manipulations appear to be cumbrous, but one soon becomes thoroughly familiarized with them through habit. XIII. TECHNIQUE OF AN ASEPTIC OPERA- TION. Whenever time allows, the following series of preparations should precede all important opera- tions. One or more baths should be given the patient to cleanse thoroughly the surface of the whole body. Before this, the patient's urine should be examined wdth the cjreatest care as soon as he has entered the hospital. Only soft and easily-digested food should be allowed. If the bowels have not been evacuated, a laxative 240 SURGICAL ASEPSIS. must be administered. Where ulcers and ecze- mas are present, their cure should be effected, if possible, before the operation is performed. In operations upon the stomach, the intestines, or the vagina, irrigations, especially enemas or douches, should first be employed ; for preliminary prep- arations on other parts of the body see Section IV., on Prophylactic Disinfection. In urgent cases, such as a herniotomy for an incarcerated gut, such preparations, unhappily, cannot be made, as life may depend upon immediate ope- rative interference ; but the well-trained aseptic operator knows how to adapt himself to the emer- gency, and will even then, by rigidly carrying out the principles of prophylactic disinfection, especially upon the field of operation, maintain his position as master of the situation. The surgeon should be surrounded by a staff of well-trained assistants and nurses, to each of whom his or her place must be assigned, and whose duties are well outlined, so that every one does exactly what is ordered, and nothing else. The surgeon should make it a special rule to prepare all the material necessary beforehand, so that during operation everything is ready and within easy reach. The running around of assistants or nurses while an operation is going on is always a symptom of defective knowledge or valuation of surgical asepsis. The surgeon SURGICAL ASEPSIS. Plate VII SURGICAL ASEPSIS. Plate VIII. ^ lO TECHNIQUE OF AN ASEPTIC OPERATION. 24I should personally superintend the necessary preparations, and should not depend too much upon other persons. Therefore his presence at least three-quarters of an hour before the opera- tion is advisable. It is always important to give the nurses a thorough understanding of the enormous respon- sibility resting upon them, even if they merely handle a piece of gauze or a needle. They, as well as the surgeon himself, should bathe daily, and they should always wear freshly-washed suits. In the operating-room there should be kept readv for the suro^eon and his staff, as well as for the nurses, a number of sterilized suits (PL VIII., Figs. I, 2, 3) to cover the entire body. These suits should be of some light material, twilled muslin and light linen being useful for the purpose. The sleeves of the coats should cover the upper arm only. During operation the surgeon's suit may happen to come into contact with the cloth- ing of an assistant : if the latter also wears a sterilized coat, no mischief will be done by such contact ; if, however, the assistant's coat is not sterilized, pathogenic microbes may settle upon the surgeon's coat, and by further contact con- tamination of the field of operation may be pro- duced. In private practice, if such suits are not available, sterilized shirts may be substituted. 16 242 SURGICAL ASEPSIS. The head also should be covered with a cap, as In bending over the field of operation it often happens that the heads of the surgeon and his assistant come into contact. Such caps are best sewed to the operating-suit. Long beards are a disadvantage, and, if their possessors do not feel like sacrificing them on the altar of asepsis, must be protected. Before the operating-suit is put on, coat, waist- coat, collar, and cuffs should be removed, and care should be taken that the hands do not after- ward come into contact with the clothing. The time required for preparations nowadays generally exceeds that necessary for the opera- tion, and it is true that the urgent necessity of observing the many minute details demanded by asepsis is its most disagreeable feature, but at the same time is the conditio sine qua non for success. Aseptic virtues arise more from a touch of character than from a capacity learned by edu- cation. There are some surgeons born aseptic, so to say, and others who will never be able to become thoroughly aseptic, no matter how often they are admonished. Operative skill, desirable as it is, at the pres- ent time does not possess half the degree of importance attaching to this particular feature of character ; and it will often be noticed that TECHNIQUE OF AN- ASEPTIC OPERA TION. 243 the operations of less skilful surgeons, performed with a comparatively small degree of dexterity, are more successful in their final results, pro- vided they are thoroughly aseptic, than the operations of surgeons less scrupulous in their preparations, even though the technical work be performed with the greatest possible elegance. About one hour before the operation is per- formed, there are put into the steam sterilizer in the operating-room the gauze, the dressing materials, etc., which, after being sterilized, are placed in metallic boxes standing on glass tables near the operating-table, within easy reach of the surofeon and his assistants. When the materials are not in use they may be covered with pieces of sterilized linen. In a box or a basin there should be kept ready a large quantity of different-sized gauze mops, which at the beginning of the operation are handed to the surgeon or to his assistant by the attendinof nurse. Shortly before anaesthesia is begun, the instru- ments are selected and put into the boiling soda- solution. Upon removing the instruments from the solution they are deposited in sterilized dishes or bowls, or, if such vessels cannot be obtained, upon sterilized towels placed upon a medium- sized glass table (Fig. 45), easily accessible. Cat- gut or silk sutures and the materials for drainage 244 SURGICAL ASEPSIS. should also be close by, so that they can be handed to the surgeon by the assistant in charge of the instruments. If the writer s metal box for silk or catgut (Fig. 42) is used, it must be surrounded by gauze after being taken from the sterilizer. On another table, standing less near than that for the gauze mops, but within reach of the nurse, are placed several basins, bowls, or plates. One of the vessels should contain the necessary bandages, another the gauze for the dressings, and a third the protective material, such as moss or cotton. Before the patient is brought into the operat- ing-room — the surgeon and his staff having dis-- infected their hands according to the principles described in Section IV., and having put on their operating-suits — each assistant has his place as- signed and his duties oudined. To one assistant, who stands opposite the operating surgeon, is assigned the duties of sponging, holding the tenacula, and rendering such other assistance as may be required. Another assistant is detailed to pass the instruments. This assistant keeps an accurate list of all the instruments needed in the various operations ; this list must be consulted be- fore putting the instruments into the sterilizer, to be sure that everything required is well prepared. If the latter assistant does not possess the un- limited confidence of the surgeon, he had better TECHNIQUE OF AN ASEPTIC OPERATION. 245 be dispensed with, the instruments being placed within the surgeon's reach. A third, the most rehable assistant, is charged with the anaesthesia. After the assistants and the nurses have been inspected by the surgeon and their aseptic con- dition has been approved, they are ordered to the positions to be occupied during the operation. A table or a chair is then placed about twenty inches behind (to the right of) each assistant and nurse. These tables hold large wash-basins containing hot bichloride solution (i : 1000-5000), which is to be used under the circumstances previously alluded to (p. 243). No conversation is to be permitted about the operating-table, so that the surgeon's commands may be audible to all and be promptly obeyed. Should an instrument, a towel, a bandage, or a dressing drop to the floor, an attendant especially assigned to this duty, and who is regarded as non-aseptic, must at once take up the article and either throw it into a pail or tie about it a piece of bandage or a ribbon to indicate its useless- ness for the operation. Instruments or dressings thus vitiated may again be rendered sterile, how- ever, by replacing them in the sterilizer. Nothing should be required of the ntcrses except to hand to the surgeon the gauze mops, the towels, and the dressing materials, and to attend to the solutions, etc. They should under- 246 SURGICAL ASEPSIS. Stand that after once being- disinfected they must not touch anything that may be contaminated. If a nurse or an attendant has to perform any non-aseptic manipulations — such, for instance, as holding the patient in a certain position or putting away a pus-basin — he should not do any work which may bring him into contact with the wound except he has worn sterilized gloves dur- ing such manipulations and has taken them off thereafter. It is preferable to have an extra room in a hos- pital for ancBsthetizing patients (PL X., Fig. 2), that they may not witness the necessary prelim- inary arrangements for the operation. If such a room cannot be had, the patient should be anaes- thetized without delay on the operating-table, as it is cruel and apt to excite the patient if he lies conscious on the table where he can see the instruments, etc. Shortly before the anaesthetic is administered the patient should be surround- ed with a large sterilized linen bed-sheet or be put into the sterilized operating-suit devised by the writer (PL VII. ; PL VIII., Fig. 4). The writer has found it useful to have these sterilized linen suits, of different sizes, ready for all operations on the body or on the extremities of the patient. The suits are made somewhat similar to a strait- jacket, openings being left in the middle of the abdominal part, in the part over the chest, and SURGICAL ASEPSIS. Plate IX. SURCxICAL ASEPSIS. Plate X. TECHNIQUE OF AN ASEPTIC OPERATION 247 at both wrists ; the latter openings are to permit feehng of the pulse. Wherever an incision has to be made there may be cut into the linen jacket a hole which may be sewed up after each use of the dress. In private practice a sheet, if prop- erly applied, would answer the same purpose. As soon as the patient is partly anaesthetized, he is brought into the operating-room. The ope- rating-table is prepared in the manner described in Section V. Prophylactic disinfection is carried out once more in the most rigorous manner, after the field of operation has been exposed and sur- rounded by sterilized cloths taken directly from the sterilizer. The surgeon's hands, as well as the operating instruments and the aseptic mate- rial, must be prevented from coming into contact with the undisinfected portions of the patient's body in the neighborhood of the field of opera- tion. The instruments in the mean time may be laid upon sterilized trays or towels, thus pro- moting the work if speed is required. In operating upon an extremity, if the writer's jacket is not applied, both the extremities should be enveloped in sterilized cloths, otherwise in- voluntary movements of the patient might bring the undisinfected limb into contact with the dis- infected one. During operation the surgeon, his assistants, and the nurses should wear linen coats (see 248 SURGICAL ASEPSIS. jpage 241 ). The condition of the coats is of the greatest importance, as nothing except the hand is apt to take up so much infectious material as they do. They should therefore be sterilized thoroughly in steam before the operation. The heads of the surgeon, the assistants, and the nurses should be covered with linen caps. Instriunents can easily be sterilized under the direct control of the operating surgeon, their disinfection requiring but a few minutes; but the materials which must be sterilized in steam require a longer time, especially catgut and gauze mops, which demand a considerable length of time for their sterilization, but which may be pre- served in an aseptic state after they have once been sterilized. Reliable druo^orists should be induced to keep such materials in stock, so that they may be obtained at any moment. But owing to the grave responsibility associated with sterilization, it seems preferable to the writer that the trouble should be taken of personally disin- fecting the materials. Towels as well as gauze may be sterilized a few days before the operation, and they may then be preserved in proper metallic boxes until required. This preparation in advance is a great convenience, as by it much time can be saved, but greater security is guaranteed if sterilization is done immediately before the operation. TECHNIQUE OF AN ASEPTIC OPERATION. 249 Better to illustrate the views of the writer, it is advisable to describe in detail the procedures before and during an operation. Supposing a radical operation for inguinal hernia is to be per- formed on a Tuesday at lo a. m. : The patient is given a warm bath on the previous Sunday, spe- cial care being taken with the inguinal region, which is scrubbed and shaved. The scrotum and the inguinal region being also thoroughly scrubbed and shaved, the patient is put in a bed supphed with fresh Hnen sheets, etc. A poultice of green soap (see p. 96) is then applied to the field of operation, and after having remained there for three hours is scrubbed away again, thus removing as much epithelium as possible. The w^hole area is' then protected with com- presses or with a towel saturated with bichloride solution (i : 1000). On Monday the same pro- cedures are repeated. At 7 A. M. on Tuesday, the day of operation, a small cup of coffee and a cracker may be allowed the patient. If more nourishment is taken, vom- iting may set in, which is apt to interfere seriously with the aseptic state of the field of operation. About 8.30 A. M. there are put into the steam- sterilizer in the operating-room the gauze, the dressing materials, etc., which, after being ster- ilized, are placed in metallic boxes standing on glass tables near the operating-table, within easy 250 SURGICAL ASEPSIS. reach of the surofeon and his assistants. Dishes or bowls, silk, catgut, material for gauze mops, etc. in sufficient quantity are kept ready, the instrument list should be consulted once more, and the operating-table must be prepared. The surgeon, his staff, and the nurses are thoroughly disinfected and are assigned their duties. After everything is prepared and the patient has been put into his jacket the anaesthesia is begun. When the patient is half anaesthetized he is brought upon the operating-table. The field of operation may now be exposed, and the inguinal region, as well as the scrotum, the abdomen, and both thighs, be scrubbed again energetically with soap and warm water. The whole area is then dried with towels and is again washed with alcohol and the bichloride solution. Sterilized towels to surround the field of ope- ration are then taken from the sterilizer and pinned together with sterilized safety-pins. The penis should also be surrounded with sterilized gauze. In female patients the pubis should be shaved and the vagina be kept packed with ster- ilized orauze. After the incision, at least three inches in lenorth, has been made over the hernial tumor, the various structures are carefully divided. Be- fore the sac is reached each bleeding vessel is caught with forceps and is at once ligated. It is TECHNIQUE OF AN ASEPTIC OPERATION. 2$ I quite customary to wipe a bleeding surface with a sponge in a forcible manner. This is wrong. If a sponge is gently passed along the line of incis- ion for one second and is then withdrawn, the purpose is accomplished and the operating sur- geon is least hindered. Considerable capillary hemorrhage must be checked by compressing the surface with pieces of gauze for a greater length of time. The sac is then pinched up by a pair of mouse-tooth forceps, and into it a small opening is made through which a grooved direc- tor can be introduced. Further division under the guidance of the director is now made, the surfaces being so separated by tenacula that a thorough inspection may be made. The sac is nov/ dissected out carefully and is cautiously separated from the cord. After wip- ing the blood-coagula from the intestine the lat- ter is replaced in the abdominal cavity. The sac is then drawn down, and is either removed after being ligated with catgut or silk or treated in one of the numerous methods prescribed. While the wound is covered and compressed with ster- ilized gauze the vicinity of the field of operation is thoroughly cleansed, the blood especially be- inor removed ; it is advisable to use moist eauze mops for this purpose, and after having dried this area the gauze is removed from the wound. If the slightest hemorrhage be noticed, additional 252 SURGICAL ASEPSIS. ligatures must be applied. The wound-surfaces may be united only after they have become per- fectly dry. Where coaptation is imperfect there must be used buried sutures, which only excep- tionally will be needed after the operation de- scribed. After the field of operation has been cleansed again it is covered with sterilized gauze, which should exert more or less pressure. Excellent immobilization is obtained if a large piece of sterilized moss-board surround the abdo- men and the thighs. By splitting the board in the middle of its lower portion (Fig. 34), which is to lie above the perineal region, splints for both thighs can be secured, as shown on page 122. In restless patients the employment of such im- mobilization is of great importance ; it generally answers the purpose so perfectly that plaster of Paris may be dispensed with. If no disturbance is observed after the opera- tion, the dressing may remain for at least one week ; it should then be removed. A part of the sutures also should be removed if silk has been used. A fresh light dressing should be ap- plied, and be allowed to remain for another five or six days, or until perfect recovery is assured. The preparations described above should be made before any other operation, be it a lapar- otomy, a resection of a shoulder, or an amputa- tion of the mammae. Some surgeons think that ASEPTIC INJECTION. 253 they are bound to make such preparations when they intend to perform a laparotomy, but do not observe any such precautions in so-called "minor surgery." There is no mmor surgery. The same principles stand for the operation of an ingrow- ing toe-nail as for an abdominal section. It is not so infrequent that death has followed even the simplest surgical operations when they were performed with a disregard of aseptic rules. XIV. ASEPTIC INJECTION. A hypodermic syringe is a surgical instrument, and it must be sterilized upon the same princi- ples as other constituents of the surgical arma- mentarium, lest it may prove a source of serious infection. Before making an injection the skin of the patient as well as the hands of the surgeon should be rendered clean, exactly as when pre- paring for any other operation, and the fluid used must be sterilized. Syringe and needles should also be sterilized. Omission of these precau- tions has frequently caused tubercular, specific, and anthrax infection, and even death by sepsis. Morphine injections have often been reported as the cause of infection in consequence of the use of a hypodermic syringe which had pre- viously been employed on an erysipelatous 254 SURGICAL ASEPSIS. patient. Frankel recently published two cases of fatal spreading gangrene following subcu- taneous injections. The busy practitioner may probably claim that innumerable injections made without the slightest aseptic precautions have not been followed by evil consequences. This claim must be taken cum grano salis. Small abscesses following such injections do not generally come under the ob- servation of the practitioner, mainly because the patient does not call upon him for the treatment of a 'Mittle boil," which he deems amenable to home remedies. Infection, however, occurs not so often as would be expected when one considers the great number of injections made in disregard of asep- tic precautions. This is probably due to the rapid absorption of fluids taking place in the cellular tissue, the microbes there finding no conditions favorable for their development. But this fortu- nate circumstance does not excuse carelessness. So far as fluids for injections are concerned, only bacteriological investigations can demon- strate their more or less aseptic character. The drugs most commonly used for injection are morphine, atropine, cocaine, ergotine, pilocar- pine, ether, camphor, iodine, alcohol, carbolic acid, mercurial preparations, and solutions or emul- sions of iodoform. With the exception of mor- ASEPTIC INJECTION. 255 phine, atropine, ergotine, pilocarpine, and cocaine, all these drugs possess a considerable amount of antiseptic power which is apt to prevent the development and multiplication of micro-organ- isms, so that they are generally sterile. Schimmelbusch's repeated examinations of a morphine solution (i per cent., as generally em- ployed) showed the presence of from two hun- dred to three hundred microbes to each cubic centimetre. It is therefore advisable to add some antiseptic agent, such as carbolic acid or bichloride, to such solutions as morphine, atro- pine, ergotine, pilocarpine, and cocaine. Bacteri- ological investigations prove that the addition of two drops of pure carbolic acid to the ounce of a sterile injection-fluid containing such drugs suffices to keep the solution sterile for a consid- erable length of time. Alcohol, ether, bichloride, and carbolic acid do not require sterilization. Few of the drugs named above are of surgical importance so far as their utilization for injec- tions is concerned, and, with the exception of iodoform, they are used only to a limited extent for curative injections into diseased organs. Regarding the frequent employment of iodo- form for injection, the writer deems it necessary to point out its indications and effects, particu- larly as bacteriological investigations as well as clinical experience have proven its great thera- 256 SURGICAL ASEPSIS. peutic value. (Compare Section III., p. 83, and Section XL, p. 207.) If iodoform is dissolved in ether, no steriliza- tion is required, but if an emulsion is made of glycerin or oil, sterilization should not be omitted. The emulsion will then generally remain sterile for many weeks. The most acceptable method of sterilizmg an emulsion of iodoform is to fill a bottle and to expose it to the steam of a ster- ilizer for about an hour. The bottle should not be closed by a stopper, lest pure iodine be set free. If a steam apparatus is not available, the oil and the glass bottle may be boiled sepa- rately, and after the completion of this process the iodoform may be added. It has been sug- gested that iodoform powder be first washed with a solution of bichloride to render it sterile. The addition of mucilage is not advisable, on account of the great difficulty of thoroughly ster- ilizing it. Good emulsions, easily kept sterile, can be made with glycerin, and oil of sweet almond will dissolve 5 per cent, of iodoform. The disadvantage of an emulsion or an oily solution is that it cannot be forced through a hypodermic needle. Ethereal solutions do not present this obstacle to their use. Since it is a recognized fact that at least one person out of every seven dies of some form of tuberculosis, the great importance of antituber- ASEPTIC INJECTION. 257 cular agents is evident. Iodoform undoubtedly possesses antitubercular properties to a marked degree. Bruns, Nauwerck, and Stubenrauch found, after injecting iodoform glycerin into tubercular abscesses (commonly called '' cold abscesses"), that the tubercular structures were substituted by firm, normal, vascular tissue. The tubercular area underwent fatty degeneration and necrosis ; later on cicatrization took place. These experiments prove that iodoform pos- sesses decided tuberculocidal influence. It is still an open question whether the destruc- tion of the bacilli is exclusively due to the pri- mary effect of iodoform upon tuberculous tissue, as maintained by Troje and Tangl in consequence of their interesting experiments, or whether indirectly the alteration of this tissue, which is a favorable soil for the bacilli, is the cause of their destruction. Practically, however, it makes no difference whether this tuberculocidal influence Is a direct or an indirect one. In tubercular abscesses, such as are often found In joints, for instance, iodoform must be used in comparatively large quantities. Long before the Investigations reported above verified this necessity, clinical experience showed clearly that when small quantities of iodoform were Injected Into tubercular abscesses cultures of the bacillus tuberculosis were generally obtained, but the 17 258 SURGICAL ASEFS*IS. same evidence could never be furnished when large quantities were used. Stubenrauch endeavored to inoculate animals with tuberculous tissue obtained from lodoform- ized tubercular abscesses, but In no case did he succeed In producing tuberculosis when he used large quantities of the drug. In the treatment of tuberculous joints, psoas abscesses, tuberculosis peritonei, etc. Iodoform oil Is especially recommended (compare p. 262). If the joint contains no fluid, the Injections will have to be made at different points each time, a needle of large calibre being required. If the different foci contain large masses of cheesy material, or If necrotic bone be present, a cure cannot be effected by this process, but when only fluid, such as pus, Is present the chances of success with Iodoform Injections are more favor- able. That the Iodoform may come In contact with all surfaces and sinuses of the cavity, the latter must first be emptied. The antltubercular influence of Iodoform Is intensified if hypercemia in the tubercular area Is produced, the iodoform injections then being made after the principles described below. Hy- percemia seems to produce conditions unfavor- able for the development of tuberculosis. Rok- itansky has called attention to the fact that con- gestions of the lungs in persons suffering from ASEPTIC INJECTION. 259 heart disease or from kyphosis are apt to render them immune against tuberculosis pulmonum. Even in patients who, while suffering from well- marked tuberculosis, acquired other pathological conditions which caused congestion of the lungs, perfect recovery from their tuberculosis was ob- served. The value of artificial hypercEmia for therapeutic purposes is therefore obvious. Hy- peraemia can best be produced by making a slight constriction above the tubercular focus. Bier advises surroundinor the tubercular extrem- ity with linen bandages below the diseased area and applying an Esmarch bandage above it, so as to cause venous stasis in the periph- ery. As the rubber bandage produces consid- erable pressure, it is advisable to put a piece of cotton or linen beneath it. Furthermore, it is advisable to change the dressings at least twice a day. The ends of the rubber bandage should be fastened by forceps instead of by making a knot, lest the latter cause excessive compression. Bier's method, however, should be recommended, for obvious reasons, only for hospital practice. For making injections the writer devised an irrigation trocar (Fig. 56) which materially differs in construction from other trocars, in that it admits the introduction of a second canula after the stylet has been withdrawn. This second canula con- sists of a double-barrelled tube. Through the 26o SURGICAL ASEPSIS. smaller of these tubes, which may be connected with an irrigator, a sterilized liquid can be in- jected. The larger tube permits the escape of those solid particles which generally may be ex- pected in the pus of such cavities as those al- FiG. 56. — Beck's irrigation trocar. luded to above. Iodoform In glycerin or in oil can then be injected through the larger tube either by an irrigator or by a piston syringe. The advantages of this instrument are that it can easily be rendered sterile in a boiling soda- solution, and that the force of the irrigation stream dislodges solid fragments and carries them off with the recurrent flow. At the same time the force of the water can easily be regulated. The trocar should be introduced at a distance from the most prominent point of the swelling, the better to conduct it through healthy skin- tissue. The skin should be drawn to one side, so that after withdrawal of the trocar the wound- canal of the deep tissues is not situated imme- diately beneath the wound in the skin. The opening in the skin must be sealed with iodo- form collodion after the operation is completed. ASEPTIC INJECTION. 26 1 The average dose employed for these Injec- tions should be between 4 drachms and i ounce, and their strength should be lo per cent. Injec- tions may be made at intervals of one or two weeks until evidences of satisfactory repair are obtained or until three or four injections show no result, in which event operative interference should no longer be delayed (compare p. 264). Immobilization is necessary so long as the patient is under treatment. In children moss splints (Fig. 34) are most useful ; in adults fenes- trated dressings of plaster of Paris are advisable. In spondylitic abscesses orthopaedic appliances are indispensable for support. The results obtained by many authors, notably Konig, Krause, and Senn, who report cures in 50 per cent, of their cases, and those in the writer's practice within the last few years, in thus treating occluded tubercular abscesses, are so very en- couraging that it seems no less than a crime to perform resection of a joint except after iodo- formization has failed. If it is borne in mind that iodoform has un- doubtedly cured tuberculosis, and that even sim- ple opening of the abdomen^ — that is, exposure to atmosphere and light — is apt to produce such metamorphosis in a tubercular nodule as to trans- ^ " Tubercular and Suppurative Peritonitis," New York Medical Jojirtial, April 21, 1894. 262 SURGICAL ASEPSIS. form It into innocent scar-tissue, we may be justified in hoping that the near future may bring about such improved methods as will effect a perfect cure of this most dreadful disease. As shown before, iodoform in oil or in glycerin proves ineffectual as a parenchymatous injec- tion into solid tumors or into elands or o-oitre ; nor will it serve for circumvenous injection in hemorrhoids, varices, or varicocele, as it is im- possible to force a sufficient quantity through a small hypodermic needle. An ethereal solu- tion is the only available form in such cases, as it \vill readily pass through the finest needle. The disadvantageous features of ethereal solu- tions are — first, intense pain for a minute or two after injection ; second, the likelihood of gan- grene of the overlying tissues in consequence of over-distention from volatilization of the ether. The evil effects from injections of ethereal solutions are due not to the iodoform, but to the ether. It cannot be denied that an ounce of ether injected into a cavity, whether or not the ether be mixed with iodoform, is fraught with danger. Gangrene caused by over-distention from the volatilization of ether can be avoided by injecting deeply into the tissues. Ethereal injections into solid tumors may, as a rule, be made every second or third day. If symptoms of inflammation follow the injection, ASEPTIC INJECTION. 263 fomentations of acetate of aluminum should be applied until the swelling subsides. When but one hypodermic syringeful is employed iodoform intoxication need never be feared. A fatal termination to a case wherein the ethereal solution of iodoform was employed is reported by Barvis.^ The patient, a man twenty- four years old, had a cold abscess in the left thoracic region. After evacuating the pus from the cavity Barvis injected over 2 ounces of a sat- urated ethereal solution of iodoform. Collapse immediately followed, proved fatal, and was attrib- uted by the author to the action of the iodoform. The speedily fatal result, however, makes it ap- pear as if some of the fluid entered the pleural cavity, where the rapidly evaporating ether was quickly absorbed. Had an innocent combination, such as oil, for instance, been combined with the iodoform used in this case, evil results would probably not have supervened. It may be stated in this connection that suppu- ration following the use of oleaginous mixtures of iodoform has never occurred in the writer's experience. Olive oil, being the mildest and most innocuous constituent, should always be employed when large quantities of the emulsion are required. Glycerin is unobjectionable only ^ " Du Traitement des Abces Froids : Intoxication lodoformique Mor- telle," Archives de Medecine et de Pharniacie, Tome xvi., No. 8, 1S90. 264 SURGICAL ASEPSIS. when used In quantities not exceeding an ounce in adults and comparatively less in children. Absorption is more apt to take place from joints than from so-called ''cold abscesses," their membranes generally absorbing slowly. The symptoms of glycerin-intoxication, which occurs much more easily in children than in adults, consist of a slight elevation of the tem- perature and an acceleration of the pulse. In the urine red blood- corpuscles are always found, and in severe forms cylinders are detected, this indicating great irritation of the kidneys. In spite of these disadvantages, the writer could not be induced to give up the combination of iodoform and glycerin, especially in the treat- ment of tuberculosis, as the slight inflammatory reaction following the Injection of iodoform-glyc- erln seems to intensify the influence of the Iodo- form upon the tubercular tissues. Enlarged glands of the neck generally yield to iodoform-ether injections. This treatment, however, is usually inefficacious In glands whose centres have undergone caseous degeneration. In such cases, if three or four Injections, made at Intervals of two or three days, prove unsuccess- ful, extirpation is indicated. It is evident that by following these principles a diagnosis ex ptvari- tibus et nocentibus can be made ; In other words, that if, after three or four injections, the gland ASEPTIC INJECTION. 265 has not decreased In size, caseous degeneration of the centre of the gland may be assumed, and extirpation should then be delayed no longer. The same course is advisable in joints, which should be resected if no improvement is obtained after three or four injections of iodoform. In reference to the treatment of the compara- tively rare form of tuberculosis of the perito- neum (compare pp. 85 and 261) the following conclusions may be offered : 1. The injection of an iodoform mixture (i : 10) into the peritoneal cavity exerts a specific anti- tubercular action. 2, The diagnosis of tubercular peritonitis in the early stages being possible only in excep- tional cases (for instance, in the serous form)» and injection of iodoform being useful in other peritonitic processes, it is particularly indicated in all doubtful cases. Iodoform in powder or In solution is indicated also after laparotomy w^ienever it is desirable to limit the discharges ; furthermore, it appears that absorption of the products of the microbes becomes less virulent in its results by the co- absorption of Iodoform. Ordinary hypodermic sy^dnges can be sterilized only with great difficulty, the inaccessibility of the piston proving a decided obstacle. Robert Koch therefore discards the piston altogether, 266 SURGICAL ASEPSrS. substituting a rubber bulb to drive out the con- tents of the syringe. But by the adoption of this bulb one of the most valuable dia^rnostic qualities of the syringe — namely, aspiration — is almost entirely lost. Further, the Koch syringe cannot be used for the injection of emulsions. These are points sufficient to prevent the adop- tion of Koch's syringe in general practice. The most convenient syringes are the asbestos syringes (Fig. 57, a and b) ; but all syringes the pistons Fig. 57. — a, Overlach's syringe; b, Meyer's syringe. of which consist entirely of asbestos work excel- lendy for a certain length of time, but soon prove ineffectual, as the asbestos easily gets out of order. It is evident from the principles empha- ASEPTIC INJECTION. 267 sized in this work that preference should be given to such syringes as can be boiled in a soda-solu- tion. It is a rather unfortunate fact that ordinary- hypodermic syringes will not stand the solution without injury. Much, however, can be done by drawing boiling water through them, w^hich is usually not injurious. The best aseptic syringe know^i to the writer is the one devised by Schmidt of Berlin (Fig. 58). It is made entirely of metal, so that boiling does not impair its useful- ness. The cylinder of the syringe, as well as the hollow piston, is made of nickel alloy. The elastic piston is tightly fitted to the walls of the cylinder and glides freely through it after being anointed with glyc- erin. The ingenious hypodermic syringe devised by Hotzen of New York is constructed upon similar principles, the only drawback being that a piece of cork must be con- nected with the piston. The needles can easily be rendered sterile by being boiled in a soda- solution. If they are made of platinum, they can also be sterilized in the flame of an alcohol lamp. Fig. 58— Schmidt's aseptic syringe. 268 SURGICAL ASEPSIS. XV. ANAESTHESIA. The entire civilized world owes an untold debt of gratitude to America for the benefit of many important inventions and discoveries. However great the best of these may be, none can equal in importance to suffering humanity the discovery in 1846, by Dr. W. T. G. Morton of Boston, of the anaesthetic properties of sulphuric ether. This discovery marks an entirely new era in surgery. Before that time painless operations were impossible ; thenceforth anaesthesia became a tangible reality throughout the whole world. The merit of Morton's discovery is not at all impaired by the fact that Dr. James Y. Simpson of Edinburgh a year later discovered chloroform, the great rival of ether. Much time has since been wasted in discussing the relative merits and demerits, advantages and disadvantages, of these two agents. A satisfactory setdement of the question is yet to be hoped for. It is not aston- ishing that drugs capable of depriving a person of consciousness to the degree of rendering him insensible to pain are not free from danger. Nevertheless, the proper administration of either drug, and careful watching, will reduce the danger to a minimum. The writer, if interro- gated by the patient as to the possible dangers of anaesthesia, compares it with a sea-trip, the ANESTHESIA. 269 dangers of which are known, although ordinarily not feared. It could hardly be that the administration of either of such powerful drugs as ether and chloro- form should not produce some changes in the various organs of the body (especially in the brain, heart, lungs, and kidneys), at least during the time of administration. That there are such changes is evidenced by the fact that in 300 cases of ether anaesthesia occurring in the writer's practice, albumen was found twenty-seven times after the anaesthesia, while before it not a trace of albumen could be detected. The lenorth of time o the ether remains in the system can be inferred by the odor ex ore, which sometimes can be noticed so late as three days after operation. In urine passed after an ether anaesthesia a more or less decided smell of ether can always be detected. We are necessarily quite In the dark as regards the poisonous action of anaesthetics, as most experiments that might reveal the cause cannot be made upon living subjects. For a long time chloroform was enthusiastically held in favor in Europe, but recently the agita- tions of French and German sureeons have caused it to be supplanted gradually by ether. The views of suroreons reo^ardine the relative value of chloroform and ether vary widely, but 270 SURGICAL ASEPSIS. there can be no doubt that each of these drues has its advantaores and disadvantages. Ether should not be administered in cases of atheroma of the arteries, nor in renal or pul- monary disease. In kidney diseases it is apt to cause suppression of the urine. In diseases of the respiratory organs, such as asthma, emphy- sema, bronchitis, etc., the vapor of the ether irritates the bronchi. In operations on the face or in the mouth, in which cases it is impossible to keep the patient constantly anaesthetized, ether is also contraindicated. There are patients who, although apparently healthy, have a sensitive mucous membrane of the respiratory tract, so that they show a high rate of respiration in ether anaesthesia. They also cough even in deep anaesthesia. In such cases chloroform should be substituted. In diseases of the heart the administration of chloroform is extremely dangerous ; therefore ether should be given in such cases. The choice of an anaesthetic and its correct administration are of as great importance from the aseptic standpoint as they are on the score of anaesthesia proper. Indeed, the aseptic con- dition of the patient may be impaired seriously should there be required the manipulations neces- sary for resuscitation from asphyxia. No sur- geon should ever neglect to admonish a patient ANESTHESIA. 2/ 1 regarding abstinence from food the morning the operation is to be performed under anaesthesia. But these admonitions, if not seriously made, are often disregarded in private practice, as is shown by the prodigious quantities of partly-digested food sometimes vomited by private patients during and after anaesthesia. The danger of omitting this precaution is multiform ; but pri- marily it is manifestly a risk to the aseptic con- dition of the wound, especially when the wound is in the head, the neck, or the chest. It is im- portant, therefore, that the mouth be kept turned from the side on which the wound is situated, lest the vomit contaminate the wound and thwart all aseptic endeavors. It is evident that the very first effort at vomiting must be met by prompt action directed especially to prevent wound- contamination. The condition of the inhaler merits close attention. It may readily become infected in operations upon septic, diphtheritic, and erysip- elatous cases. The frame of a chloroform-inhaler should consist of metal, preferably wire, which can be rendered sterile by boiling, and should be so arranged that it can be covered with a few layers of sterilized gauze. For private practice the writer has devised a mask made of two wire frames which can be folded together like a note- book and be carried in the pocket. 2J2 SURGICAL ASEPSIS. For ether anaesthesia any one of the many cones or inhalers may be used, or a simple apparatus may be improvised by folding into a cone a sterilized towel supported by thick paper or pasteboard, and fastening it with safety-pins. The writer has a predilection for the " Clover inhaler," which has the great advantage that the anaesthetizer, by measuring the amount of ether inhaled, is able to regulate its administration. This inhaler also excels by its rapidity in pro- ducing anaesthesia. Before and durinor ether or chloroform anaes- thesia the following rules should be observed: 1. The urine should always be analyzed, espe- cially before the administration of ether, and the heart and lungs must be examined carefully. 2. Foreign bodies, such as false teeth, tobacco, etc., must be taken from the mouth. 3. The clothing must be loosened to prevent even the slightest constriction of the circulation or the respiration. 4. The patient should assume the dorsal decu- bitus, as syncope may occur in the sitting posture. His head should rest low, on a small pillow, so that it is in line with the body. 5. Before the chloroform-inhaler is applied the lips and the face should be anointed with vaseline as a preventive of irritation and excori- ation. ANESTHESIA. 273 6. The patient should be instructed to close his eyes and to take deep, full, and regular res- pirations. His attention should also be called to the fact that the first inhalations, although dis- agreeable, do not subject him to danger. If he shows symptoms of excitement, he should be calmed and encouraged by kind words. Ner- vous patients sometimes struggle considerably after they have made but one inspiration. This occurs especially under ether. In such cases it is well to drop the mask and to explain that further proceedings will be impossible until the patient remains quiet. Such statements should be made in the kindest manner, otherwise the patient becomes indignant over the lack of sympathy on the part of the anaesthetizer, and it is difficult then to calm his excitement. 7. Chloroform must be administered, slowly, and mixed always with a sufficient quantity of air. If ether is given, this precaution is unneces- sary and may delay anaesthesia and waste the ether, but in case of cyanosis breaths of pure air should be allowed until the cyanosis has disap- peared. 8. The surgeon should not begin an operation until the patient is fully under the influence of the anaesthetic, or ''in surgical anaesthesia," which is indicated by paralysis of the palpebral reflex and by relaxation of the voluntary muscles. 18 274 SURGICAL ASEPSIS. 9. Good ventilation should be had in the ope- ratino-room. 10. Whenever possible, operations by gas-, candle-, or lamp-light should be avoided. Aside from their insufficiency, they are a serious men- ace, on account of their liability to cause an ex- plosion by igniting the vapors of ether. 1 1 . The safest way of administering chloro- form is to let it continuously fall upon the inhaler from a dropping-bottle. A Braatz inhaler (Fig. 59) is a very useful apparatus for the purpose. 12. The pupils should be watched to ascertain if they are dilated or if they respond to light. Dilatation or their failure to respond to light must be viewed as a sign of approaching danger. Repeated testing of the corneal reflex, however, is not wise, as a much more reliable index for full anaesthesia is represented by the rate Fig. 59.— The g^i-^^i character of the respiration. Braatz inhaler. r^ r ^ ^ 1 13. Careiul and permanent control of the pulse and respiration is of the greatest importance. In fact, the respiration needs more attention than the pulse. Quickening of the res- piration, as well as weak pulse or respiration, may denote that too much of the anaesthetic has been administered. Loud stertor in chloroform anaesthesia is also an alarming symptom, as it in- ANESTHESIA. 2/5 dicates epiglottidean closure of the larynx. If any such disturbance is observed, the anaesthetic must be discontinued instantly. If falling back of the tongue has occluded the larynx, the lower jaw must be pushed forward and the tongue be drawn out with forceps. At the same time the thorax should be elevated, so that the head and neck may fall back. By this manipulation the point of support of the tongue is changed from the posterior pharyngeal wall to the palate, by which procedure the space between the pharynx and the root of the tongue becomes free. Mucus, which is apt to accumulate in the mouth or the throat, especially under ether anaesthesia, must be removed from time to time. This removal is best effected by thrusting into the pharynx a sponge attached to a holder, while the jaws are kept separate with a maxillary separator (Fig. 6i). 14. For at least five hours before the opera- tion the patient should eat no solid food, nor should liquid food be allowed later than three hours before the operation. Some brandy and cracked ice may be administered shortly before the operation, or, if the padent is weak, hot brandy or claret may be injected into the rectum. Habitual drinkers and very nervous individuals should receive a hypodermatic injection of mor- phine (^ to ^ grain) twenty to thirty minutes 2/6 SURGICAL ASEPSIS. before the anaesthesia is commenced. Morphine injection should also be performed before opera- tions on the face, the mouth, the pharynx, or the nose, in which cases the operation should be be- gun the instant perfect anaesthesia is established. All patients are liable to accident during anaes- thesia, despite the most careful precautions. Vomited material may enter the larynx, or the tongue may fall back and press the epiglottis against the entrance to the larynx. Most of these accidents are attributed to cardiac par- alysis. Accidents may, however, be due to an overdose of the anaesthetic, as well as to a spe- cial pathological condition of the heart, the cha- racteristic signs and symptoms of which condition were not recognized by the surgeon : this condi- tion is vaguely termed an ''idiosyncrasy," and its victims may appear to be in perfect health. Many deaths during or after operations, from what is vaguely termed " shock," are doubtless closely related to the effects of anaesthetics. If all such cases could be analyzed minutely, and if all accidents of this kind were published, the death-rate would be swelled considerably. It is quite human that a surgeon is much more prone to attribute a fatal result to "shock" than to some omission or to the effects or after-effects of an anaesthetic. If any of the above-described symptoms are ANAESTHESIA. 277 threatened, the administration of the anaesthetic should at once be discontinued, and it should only be continued slightly if the pulse remains weak. In cases where the functions of the organs of the chest are much impaired by compression through a serous or purulent effusion — In the thorax, for instance — only a few drops of chloro- form should be poured upon the inhaler. The same caution should be observed in cases of sepsis and of burns of the third degree, where through the absorption of toxines, which are severe heart-venoms, the heart's action is so much depressed. Patients afflicted with such conditions are, however, not very sensitive to pain, as the toxines exert an anaesthetic Influence. A limited a^icesthesia frequently leaves an im- pression only, and not a clear perception, of all the surgical procedures, and frequently It Is the nervous dread of these procedures, and not the physical pain itself, which terrifies the most courageous patients. The odor alone of an anaesthetic will sometimes give the patient the agreeable impression of growing, or of being, insensible to pain. If respiration becomes impaired^ operations may properly be finished without the further administration of the anaesthetic. It is less cruel to trouble the patient and to save his life than to 2/8 SURGICAL ASEPSIS. eive him the so-called benefit of full anaesthesia and to risk his life under the pretext of humanity. The forceps with which the tongue is drawn forward merits some special attention. When- ever the symptoms of respiratory impediment appear and do not yield prompdy, the assist- ant in charge of the anaesthetic should place his fingers behind the angles of the lower jaw and force the jaw forward. If breathing does not then promptly become normal, the tongue must be seized with sterilized forceps and be pulled forward. The jaws of the forceps should be built strongly, and the handles be provided with a catch, Fig. 6o. — Beck's tongue-forceps. , , SO that the mstrument can- not slip from the tongue. The writer uses an instrument made especially for this purpose (Fig. 60). In construction it is similar to a Pean forceps, the surfaces of its strongly-built blades being very broad, so as to catch a considerable portion of the tongue. An interspace, to leave room for the non-compressed portion of the tongue, is provided between the catching portion and the joint. The introduction of the forceps is frequently difficult, as the teeth may be pressed firmly to- gether, in which case the Roser-Konig mouth- forceps is of great value, as it rapidly separates vSURGICAL ASEPSIS. Plate XI. ANESTHESIA. 279 the maxillae. The writer has devised several modifications of this useful instrument, the most important of which is the establishment of grooves in the triangular mouth-piece of the forceps (Fig. 61, b). After this modified sepa- rator (Fig. 61, a) is introduced it is turned side- wise, and by forcing the grooves into the teeth Fig. 61. — Beck's modified maxilla-separator. the instrument will be prevented from falling out. The removal of mucus Is thus rendered easy. If ordinary means do not suffice to restore breathing, resort must be had to the induction of artificial respi^^ation. The writer has found it useful to combine artificial respiration with stimulation of the heart and lowerinor of the head, as illustrated by Plate XI. After having placed the patient in a position similar to that of Trendelenburg, an assistant grasps the arms at the elbows, carries them outward and upward above the head, and brings them back to the anterior surface of the thorax. This movement should be performed in a rhythmical manner and 28o SURGICAL ASEPSIS. about eighteen times per minute. At the same time another assistant thrusts his fingers against the apex of the heart, as if employing a species of massage. While these manipulations are being made camphorated oil and tincture of strophanthus may be injected hypodermatically. Many other valuable methods exist, but it is best to stick to a few, so as to become thoroughly familiarized with them and to be able to carry them out well. It appears to the writer that the procedures above described are the most reliable and are ordinarily sufficient. If consideration is ofiven to the fact that the essential difference between ether and chloroform is that the first produces an irritant action while the second exercises a depressant one, it becomes clear why chloroform is the more dangerous of the two drugs diu^ing operation. Experience has demonstrated that the great majority of deaths under chloroform anaesthesia occur at the preliminary stage, even before the surgeon can use the knife. What is the legal responsibility of an accident of this kind every physician well knows. The dangers of ether anaesthesia usually set in during its after-effect. Not a few persons with- out the slightest evidence of kidney disease die shortly after an insignificant surgical operation in which ether has been administered. Diffuse ANESTHESIA. 28 1 nephritis being found, the fatal outcome is ex- plained. But this is not the only remote danger of ether. CEdema pulmonum, broncho-pneu- monia, and collapse, according to a number of reliable surgeons, have frequently followed the administration of ether. CEdema pulmonum and collapse may take place even several hours after the operation, and are then generally not attributed to the anaesthetic. Such occurrences usually not being considered in statistics, it is natural that erroneous conclusions are drawn in reference to the "safety" of ether. On the con- trary, as in all diseases of the respiratory tract even the most enthusiastic friends of ether use chloroform anaesthesia, it is just the most un- favorable cases that are reserved for the chloro- form. Autopsies are made only exceptionally, therefore an anatomical explanation for the fatal end is rarely found. Autopsies in cases of sud- den death after chloroform generally give no explanation. It is supposed that death from chloroform is produced by fatty degeneration of the heart and by an overloading of the blood with carbonic . acid. Some physicians maintain that death would be caused by an abun- dant formation of nitrogen. As shown previously, many deaths have re- sulted from the after-effects of ether. An immi- nent peril being always much more feared than a 282 SURGICAL ASEPSIS. remote one, it seems to be natural that the dan- gers of chloroform appear the more formidable to the practitioner, who dreads a fatal collapse in the operating-room more than he does one in the sick-bed — that is, after some time has elapsed following the operation ; therefore he gives pref- erence to ether. As it stands to-day, there is no ancEsthesia with- out a possible risk. The freedom of some physi- cians, especially beginners, in the administration of anaesthetics in the treatment of triflinor in- juries and for diagnostic purposes is explainable only on the ground of their ignorance of the danger. Experienced physicians are usually more careful, and avoid anaesthesia whenever they can, their experience and diagnostic talent enabling them frequently to determine patholog- ical conditions by exercising patience and by using combined scientific methods, thus not ex- posing their patients to any risk in examination. For trifling injuries an anaesthetic should be avoided whenever possible, and local anaesthe- sia be substituted. Local ancesthesia is obtained either by the application of cold or by the use of hydro- chlorate of cocaine. For minor operations cold can best be obtained by spraying either sulphuric ether or a combination of ether, chloroform, and menthol over the surface with an atomizer for ANESTHESIA. 283 about two minutes. The integument, after at first becoming reddened, assumes a white color, and finally becomes parchment-like and insensi- ble. The structures beneath the skin are not influenced by this procedure. Hydrochlorate of cocaine, for the discovery of the local anaesthetizing power of which sur- gery will for ever be indebted to Carl Roller of New York, is invaluable in operations upon the mucous membranes, as those of the eye, mouth, nose, larynx, vagina, uterus, etc. It can be applied by a swab of cotton in a solution of from 4 to 20 per cent. In operations upon other parts of the body it may be applied hypodermati- cally in a solution of from i to 2 per cent. An Es- march bandage will prevent cocaine-intoxication and at the same time will increase the anaesthetiz- ing power of the cocaine. The injection, being of itself painful, should always be preceded by the application of an ether spray. A i per cent, solution is generally strong enough for hypoder- matic purposes. Great care should be taken to inject at different points around the proposed line of incision. A small quantity should be injected into the cellular tissues and into the deeper layers, and a larger quantity, by slowly withdraw- ing the needle, should be forced directly into the skin, so that the epidermis is gradually raised aloncr the line of the intended incision. 284 SURGICAL ASEPSIS. Operations done under local anaesthesia should be performed with special rapidity. The majority of manipulations can just as well be done rapidly as slowly; however, if speed can be exercised only at the expense of thoroughness, rapid manipula- tion would do more harm than good, and would then be one of the most dangerous, instead of one of the best, attributes of a surgeon. XVI. ASEPSIS IN PRIVATE PRACTICE. The prevalent though erroneous supposition among busy practitioners that strict asepsis can be carried out only in hospitals proves a serious obstacle to its principles being always observed in private practice. While in former years the general practitioner was envied by the hospital surofeon because he need not fear infectious dis- eases being transferred to his patient in a private residence, the general practitioner now envies the hospital surgeon because a well-equipped aseptic hospital offers superior advantages for his surgical cases. As shown in the previous sections of this work, the main difference between asepsis in a hospital and asepsis in private practice exists only in the greater amount of care and atten- tion to aseptic principles required by the latter. These principles are so simple that it seems ASEPSIS IN PRIVATE PRACTICE. 285 Strange that the majority of the profession does not recognize the feasibiHty with which asepsis may be carried out in private practice. The main difficuhy in convincing general prac- titioners seems to be that, not being sufficiently familiar with the fundamental principles of asep- sis, they dread the commission of errors which might thwart the object in view. They are more familiar with "antiseptic precautions," and there- fore declare that they "place more reliance upon antisepsis than upon asepsis, as the splendid re- sults obtained under antiseptic precautions are sufficient proof of their efficacy." But on a close examination of the so-called "antisepsis" of such colleagues there is encoun- tered great superficiality. Many deem the mere dipping of the fingers into a bichloride solution just before operation as an adequate Insurance against infection, being regardless of the condition of their hands, which only a few minutes before may have been In a carcinomatous rectum. In- struments taken from a pocket-case saturated with sweat are put into a carbolic-acid solution to whose percentage no importance is attached. Furthermore, the carbolic acid frequently is undis- solved, lying in full strength at the bottom of the vessel, the water not containing a particle of it. A thorough scrubbing of the field of operation is deemed absurd, inasmuch as after the incision Is 286 SURGICAL ASEPSIS. made irrio^ation with a strono; bichloride solution is credited with the power of washing away all the sins of omission or of any imaginable kind of commission. If, notwithstandinor these alleged precautions, it so happens that one or more microbes escape being killed, then the dusting over the wound-surfaces of iodoform powder is expected to destroy the microbes entirely. The writer has heard similar ideas expressed by colleagues who enjoyed the full confidence of the community. If, to the surprise of the "antiseptic" colleague, sepsis sets in, he emphat- ically asserts that the strictest antiseptic precau- tions were taken, and that for some unfortunate reason there must have been some agent in the system predisposing the patient to this fatal course. He has done all he could. He has not only used bichloride, carbolic acid, and iodo- form, but he has also looked the latest medical essays over and employed the most recent anti- septic preparations. But, alas ! this particular case was " beyond the reach of science." Had such a colleague but inspected his finger- nails, which perhaps sheltered millions of mi- crobes, representing a graveyard, so to say, his patient might have been " within the reach of science." This assertion would seem to place his entire knowledge of the principles of wound- treatment on a level with that of the laity, among ASEPSIS IN PRIVATE PRACTICE. 287 whom it is known that iodoform, bichloride, and carbohc acid are good antiseptic medicaments. Only a short time ago the writer met an old practitioner who had been advised to administer intra-uterine douches, and who remarked with great dignity that he was always prepared for in- tra-uterine cases in carrying a good-sized metal catheter with him. He produced a discolored instrument which looked as if it miorht have been exhumed at Pompeii. When the writer doubted the aseptic condition of the catheter this learned colleague gave a look of unutterable contempt, put the catheter to his lips, and blew through the instrument to prove that it was still permeable. Thoroughly satisfied with this pro- cedure, he exclaimed, " What objection can be found to this catheter? It is all ri^ht. It con- tains no sanoruinolent incrustations Y' Allusion to this instance is made simply to illustrate the deplorable fact that there are some men still oblivious of the advances of the times. But there is another, happily the larger, class of colleagues professionally developed to a much higher degree, who are always in the vanguard when anything new and rational appears. They are perfectly modern. A fortnight ago they fol- lowed antisepsis ; to-day they creditably strive for asepsis. They sterilize their dressing material, they boil their instruments, they possess the best 2SS SURGICAL ASEPSIS. modern aseptic appliances, and they evince a disposition to attain the very best results ; but, commendable as these efforts are, they do not go far enough. Many of them place properly- sterilized dressing materials upon an unclean lounge ; they rest upon soiled bed-sheets instru- ments which had been sterilized ; their disinfected hands, after having been brought into contact with uncleansed parts of the body, are introduced into the wound ; and other similar infractions are committed, thus violating every principle upon which asepsis is based. No stone, however, should be cast at such men, for they do the best they can. In shoi^t, non-compliance with aseptic rides is si7nply due to ignorance of them. The whole profession must be so thoroughly imbued with the princi- ples and so permeated with the practice that the exercise of aseptic rules becomes a mere matter of routine. That w^e are far from having reached this desirable stage was never more evident to the writer than when, only recently, he saw an eminent surgeon insert his hand, ornamented with several rings, into a human abdomen. If such men thus err, what can be expected of the average practitioner? When antisepsis was first broached In clinics the country physician ridiculed the new method. The writer remembers hearing an old German '* Medl- ASEPSIS IN PRIVATE PRACTICE. 289 clnal-Rath," sixteen years ago, say to his young assistant, who had been educated at Czerny's cel- ebrated cHnic at Heidelberg, when offered a brush to clean his fingers : " A brush ! what for ? All this is nothing but the arrogance of young medical men." But the old counsellor eventually grasped the idea that he could not very well disregard this alleged "arrogance," for the simple reason that the public began to know something of the antiseptic method. The present transition state is somewhat similar to the period of early Lis- terism, and it is clearly incumbent on surgical specialists to impart all possible instruction on asepsis to general practitioners. Naturally, it will greatly facilitate the introduction of asepsis if its methods are more and more simplified. But it should always be borne in mind that simplicity must not circumscribe the fundamental princi- ples of asepsis. The manner of execution of aseptic rules is well demonstrated in the preparations for opera- tion in a private dwelling. Every surgeon must be prepared to perform operations oittside the hospital, and, if necessary, amid the poorest sur- roundings. He naturally will there encounter a great many more difficulties in keeping up his asepsis than he would at the hospital. But all these difficulties will be overcome by one accus- tomed In the hospital to thorough asepsis, the 19 290 SURGICAL ASEPSIS. principles of "which he will be able to carry out amid the poorest accommodations of the back- woods. As the surgeon must always be prepared for a call, he should therefore have a set of asep- ticized surgical appliances ready in a satchel at his ofhce. The writer has found it convenient to preserve the instruments generally required in linen cases, having a separate case for abdom- inal sections, one for operations upon the bones, one for the uropoietic system, one for trache- otomy, and one for general use (Fig. 62). These linen cases may be rolled up and tied in the middle with a cord after being used. The case designated by the writer for general use contains such instruments as are required in any opera- tion — that is, scalpels, scissors, forceps, retractors, spoons, etc. — and is carried along with the one designated for a special operation. For instance, if a herniotomy is to be performed, the general set is accompanied by the laparotomy set. By keeping these linen cases always ready we may guard against the necessity of sending from the patient's house for a forgotten instrument. The pocket case devised by the writer actually represents the linen case en miiiiaiure. With a few buttons it is fastened to a leather case, and it may be carried in a pocket conveniendy. By boiling the linen sheet it can easily be rendered sterile. ASEPSIS IN PRIVATE PRACTICE. 291 The instrument-cases can be carried alone with the other necessaries In a satchel. The writer uses a satchel of rectangular shape forty Fig. 62. — Linen instrument-case (for general use). centimetres long, which gives ample space for the instruments required, as well as for the other nec- essaries, consisting of a folding sterilizer (Fig, ^^l), trays (Fig. 23) fitting one into another, gauze and cotton as dressing and sponging ma- terial, moss, bandages, silk, catgut, rubber gloves, green soap, brushes, soda, bichloride tablets, ether, chloro- form, morphine tablets, and campho- rated oil. It will sometimes be con- venient to carry the surgeon's coats, towels, sheets, etc. to the house also. i\mong the utensils the first and most Important is the boiler. Fig. 63. — Sim- ple boiling-pot. 292 SURGICAL ASEPSIS. If a physician cannot afford the luxury of a ster- ihzer, he may order several enamelled pots (Fig. 63) to take its place. A folding stand such as is described on page 1 10, costing fifty cents, may be carried in a satchel. Most patients, however, would not object to expending seventy-five cents or a dollar for a "royal baking-pan" (Fig. 64), which, being pro- vided with a small stand, is sufficiently spacious to sterilize both the in- struments and the mate- rials for an operation. The brushes for scrub- bing the skin-surfaces, if sterilized, can be carried in aseptic towels, as well as the gauze and other dressing material. The ligatures are kept best in one of the metal boxes described on pages 135 and 136. Iodoform gauze may be carried conveniently in a receptacle such as the one de- vised by Duhrssen (Fig. 65). If a pot should not be at hand, it should be remembered that small instruments, such as needles, canulas, bistouries, etc., may be sterilized by boiling them in a table- spoonful of water held above a candle. The patient's family should be instructed to keep an abundant supply of boiling water ready in large vessels, and there should be at hand a Fig. 64. — Baking-pan. ASEPSIS IN PRIVATE PRACTICE. ^93 Fig. 65. — a, Aseptic re- ceptacle for iodoform gauze ; b, the case (Diihrssen). sufficient number of linen bed-sheets and plenty of towels. If the tin boilers which are so much en vogue are used, they should be scrubbed well with sapolio before being used for surgical purposes. Before being put in use they should be covered with ster- ilized towels, and the arrange- ments with the sterilized water should be supervised by an assistant or nurse. It is well to have ready several china pitchers and basins pre- viously scrubbed in the same manner as the tin boilers, and afterward washed with a stronor bichloride solution. If basins or bowls cannot be procured for the instruments, they may rest upon sterilized towels. The operati7ig-room in a private diuelling (com- pare Section VIII.) should be well lighted. It is wise to send an assistant to the house at least one day before the operation, to see that the room is prepared in accordance with the rules given on page 151. A strong table may be selected for an operating-table. In addition, there should be provided two other tables, of nearly equal size, upon which to place the instru- ments, the trays, the gauze mops, the silk, and other materials. If the extra tables cannot be 294 SURGICAL ASEPSIS. obtained, a number of wooden chairs may be substituted. Tables and chairs should be scrubbed with soap and boiling- water, and with bichloride on the day before the operation. It is also advisable to send a nurse to the patient's home at least twenty-four hours before the operation is to take place, to make the necessary arrangements in the operating-room, and to see that the patient takes a warm bath and is prepared in accordance with the directions oriven in Section IV. It is a ereat convenience for the nurse to have an operation blank such as that prepared by Dr. Keen of Philadelphia.^ On this blank all the necessary preliminary arrangements to be made by the nurse are clearly defined. It is furthermore necessary to send another assistant to the patient's dwelling at least two hours before the time set for the operation. This assistant should arrange the sterilizer by putting in the soda-solution, lighting the lamp, and depositing the instruments, towels, dressing materials, ligatures, etc. He then renders him- self aseptic as described in Section V. Having protected his hands with sterilized gloves, the assistant places in the lightest part of the room the operating-table, and arranges in their proper positions the tables or chairs for the instruments. » Published by VV. B. Saunders, Philada. ASEPSIS IN PRIVATE PRACTICE. 295 The instruments, which meanwhile have become sterile, are placed on the tables and chairs, which must first be covered with sterilized towels or with sheets, these tables being so located that the instruments are within easy reach of the operating surgeon. If much sterilized water is required, it should be brought from the sterilizing utensil in clean pitchers the handles of which are surrounded by sterilized gauze or towels. Within easy reach of the operating surgeon should also stand two basins, one of which should contain sterile water, the other one bichloride. Only after all the above preparations are finished may the anaesthesia begin. It is prefer- able that the anaesthetic be admnnistered in an adjoining room. In the meanwhile the assistant should remove his gloves and again disinfect his hands. All the other assistants and the nurses, if called on to perform any non-aseptic manip- ulations — as, for instance, helping to carry the patient upon the operating-table — should, if pos- sible, wear gloves while doing so. The operating surgeon should also be present at the patient's home as early as possible, so as to control the preliminary arrangements and to give ample time for rendering himself thoroughly aseptic. When only an ordinary pot can be obtained, the towels, etc. must be boiled in the water; this, 296 SURGICAL ASEPSIS. however, necessitates using the materials in a moist state. After the patient is laid upon a fresh linen bed-sheet, preferably a sterilized one, the field of operation must be scrubbed thoroughly with warm water and soap (compare Section IV., on Prophylactic Disinfection). The area is then dried with towels and is ao-ain washed with alco- o hoi and bichloride. Sterilized towels from the sterilizer are now taken to surround the field of operation. Before any object is removed from the sterilizer the surgeon and his assistants, and whoever else participates in any part of the operation, must, of course, have disinfected their hands. When the surgeon and his assistants are prevented from using operating-suits, the latter must be substituted by sterilized bed-sheets or shirts, or at least by one or two sterilized towels fastened over the chest and abdomen by safety- pins. During the entire operation no antiseptic fluid is required. Gauze mops cut into short pieces before sterilization answer every purpose of cleanliness. They may be wrapped in a towel the ends of which are pinned together to protect the mops. These procedures will doubtless appear strange when first employed by one unaccustomed to asepsis. The feature most likely to disconcert the inexperienced surgeon is the exclusion of ASEPSIS IN PRIVATE PRACTICE. 297 all chemicals during operation. But this initial stage of novelty soon passes off, and every step and detail quickly becomes a matter of salutary habit. The surgeon should closely scrutinize his every act, and should always bear in mind that no wound, whether clean or otherwise, should ever be treated with a non-disinfected hand. Furthermore, he should not bring into contact with the wound any article or instrument unless it has been sterilized thoroughly. The surgeon should be equally scrupulous in his private office. He should imatate the conditions of the aseptic operating-room (see Section VIII.) as much as possible, and should always have boiling water at hand. If he seriously desires to be aseptic, a few days' practice will thoroughly accustom him to the new manipulations. This remark refers especially to repeated prophylactic disinfection of his hands and of all the objects that may come into contact with a wound. This training wall teach the avoidance of manipulations w^hich may appear innocent on superficial examination, and yet may cost a human life. There is no excuse for a surgeon to claim that *' the poor circumstances of the patient's surroundings did not permit aseptic precautions." Water, fire, and boiling-pots can everywhere be obtained, so that instruments, silk or common 298 SURGICAL ASEPSIS. thread, and dressings can be sterilized. If no dressing material be at hand, old linen may be boiled and substituted. It is true that the dress- ings are then moist, but nevertheless they are sterile. Freshly-washed and ironed linen, how- ever, is generally sterile, and may be substituted for the oauze. Public attention should be called to the great importance of the above points, so as to render the aseptic surgeon valuable support. Many persons die from the consequences of having cut their corns with an unclean razor or from having opened a small abscess with a dirty pin. Had they been told that the parts should have been washed carefully and that the razor should have been boiled for a few seconds, they would not have succumbed to the most fell of all destroy- ers — ignorance. It is a widespread custom to wash wounds with water without being scrupu- lous as to its source. It may be from a muddy pool or from a dirty vessel, and be spread over the wound to "render it clean." The public should also be instructed that wounds must be disturbed as litde as possible, and that only when there is considerable hemorrhage should the bleeding region be pressed for five minutes (or until the arrival of the surgeon) with a towel or a linen compress previously immersed in boiling water. ASEPSIS IN PRIVATE PRACTICE. 2gg A most interesting paper, read before the New York Academy of Medicine (May i8, 1894) and published in the American Medico-Surgical Bulletin for June 15, 1894, by Surgeon-General Joseph D. Bryant, on "The Fallibility of Human Effort in Aseptic Surgery," illustrates what the writer has before emphasized^namely, that if ninety-nine points of precaution are originally observed, while the hundredth is omitted, the result may be the same as if no precautions whatever had been taken. Bryant wired a comminuted fracture of the patella uncomplicated by external opening. Al- though strict aseptic precautions were taken, the joint suppurated and the patient died. The sup- puration began superficially in the line of several strands of catgut placed to facilitate drainage. The question then arose as to the cause of the infection. Samples of each of the agents employed in dressing the wound were submitted to the biological scrutiny of Professor Dunham of New York, wn'th negative results in every instance. As the necessary precautions in other respects were believed to have been taken, Bryant was puzzled as to the cause oi infection. Finally, before attributing the infection to "un- known influences," he decided to take the class into his confidence. He stated to the student members the sequel to the operation and the 30O SURGICAL ASEPSIS. apparent mystery surrounding the wound-infec- tion, at the same time inviting their closest scrutiny and the frank expression of any defect in technique that might be observed in any subsequent operations. This proposition bore immediate fruit in the form of a written commu- nication from a student who modestly suggested that the infection mio^ht be due to the fact that the assistant who had plaited the catgut had placed on the table with the other instruments, without first cleansing it, a probe which had been used just before to explore an intestinal sinus. Bryant correctly says that we should not un- duly criticise the momentary forgetfulness of the assistant who thus unconsciously violated an aseptic law, but that we should recall the biblical phrase regarding " motes and beams," and make a retrospective examination of the effects of our own foro^etful moments. All honor to men who do not refrain from crit- icisine their own unfortunate cases. Thus we o profit, and in asepsis more than in aught else should be remembered the old sentence in the temple at Delphi: ''Tvddi deavrov^ INDEX. Abbe's illumination, 30 Abdomen, sterilization of, 96 Abdominal cavity, antiseptic solution in the, 57 drainage, 209 Absorbent gauze, 121 power of dressings, 121 Accidents from carbolic acid, 77 Acquired immunity, 70 Actinomyces, 46 Aerobic microbes, 27, 176 Alcohol in skin-disinfection, 93 Alummum aceticum, 81 Anaesthesia, abstinence from food before, 271 cause of death in, 276 dangers of, 243, 269 general rules to be observed in, 272 its importance for asepsis, 270 limited, 277 starting of, 246 An£esthetizing-room, 246 Antagonistic microbes, JT, Antisepsis, 53 Antiseptics, 55 Antitoxic substances, 60 Apparatus, Braatz's, for sterilizing catgut, 127 Aristol, 88 Artificial immunity, 70 respiration, technique of, 279 Ascococcus. See Staphvlococciis. Asepsis, fallibility of human efforts in, 299 Aseptic fever, 170 injection, 253 preparations before, 253 operation, technique of, in a hos- pital, 239 Aseptic operation, technique of, in private practice, 284 wounds, 159 Assignments of duties to assistants, 244 Assistance, non-aseptic, 245 Assistants, 240, 294 Atmosphere as a carrier of micro- organisms, 19 Atmospheric infection, 47 Bacilli in general, 22 Bacillus anthracis, 44 coli communis, 41 diphtheriae, 45, 68 fluorescens putidus, 74 prodigiosus, 46 tetani, 43 tuberculosis, 42 Bacteria in general, 22 Bacteriological examination, methods of making, 29 examinations before operations, 88 Bacterio-proteine, 50 Bacterium coli commune. See Bacillus coli communis. Baking-pan as a sterilizer, 292 Bandages, 124 Bathing of the patient, 95, 158, 239 Beards as an aseptic obstacle, 242 Bichloride of mercur\', 78 Bladder, disinfection of, 99 treatment after operation upon the, 214 Bladder-pistol, Beck's, 87 Blisters in infected wounds, 182 Boiling water as a disinfectant, 65 301 302 INDEX. Boric acid, 8 1 Box, metal, Beck's, for sterilizing and preserving catgut or silk, 136 Braatz's, for sterilizing catgut, 126 Schimmelbusch's, for sterilizing silk, 135 Braatz's nail-cleaner, 92 pedal, 95 sterilizing apparatus, 127 Brush, importance of, 102 Brush-box, 102 Buried sutures, 160, 169, 182 Cadaver-alkaloids, 26 Caps, linen, for surgeons and nurses, 241 Carbolic acid, 76 Catgut, boxes for preservation of, 126, 136 jars for preservation of, 128" sterilization of, 125 unreliability of, 128 Catheters, disinfection of, 99 Cavities, disinfection of, 190 renewal of dressing in, 221 Cells of microbes, 23 Cellulitis, 173 Chemotaxis, 35 Chloride of zinc, 80 Chloroform, administration of, by dropping, 274 danger of, 280 discovery of, 268 indications and contraindications for administration of, 270 mask. See InJialer. Clover inhaler, 272 Coats, surgeons' and nurses'. See Suits. Cocaine anaesthesia, 283 Coccoglia, 24 Coccus. See Micrococcus. Compound fractures, renewal of dressings in, 235 Cones for anaesthesia, 272 Contact-infection, 48, 146, 148, 150 Continued suture, 163, 216 Corrosive sublimate. See Bichloride of mercury. Cultivating microbes, 29, 33 Cystitis, microbes concerned in, 99 Dermatol, 88 gauze, 124 Dermatoses, 226 Diphtheria, treatment of, by injec- tion of serum, 73 by removal of membranes, 68 by sub-membranous injection, 69 Diplococcus pneumonia, 40 Disinfectants, influence of, on diph- theria, 68 on infected wounds, 172, 184 Disinfection, determination of the kind of, 88 general, by inoculation, 75 in a hospital, 158 of catgut, 125 of drainage-tubes, 139 of dressings, no of instruments, 104 of silk, 133 of sponges, 157 of the bladder, 99 of the feet, 95 of the finger-nails, 92 of the hands of the surgeon, 92, 93 of the mouth, loi of the mucous membranes, 97 of the nose, loi of the operating-room, 144 of the rectum, 98 of the skin of the patient, 95 of the surgeon, 103 of the vagina, 97 selection of the kind of, 188 technique of, shortly before opera- tion, 247 Drainage by gauze, 184, 208 Drainage-tubes, disadvantages of, 191 indications for, 212, 219 Draining in intestinal operations, 207 in operations upon the gall-jjlad- der, 208 in operations upon the liver, 205 in tuberculosis, 206 metlKKJical, by iodoform gauze, 190, 198 INDEX. 303 Dressing material, sterilization of, no renewal of, 214, 225 secondary, 218 Dryness, antiseptic influence of, 66 Dust in operating-room, 152 Eczema, symptoms of, 227 Electric lamps, sterilization of, 109 Electricity as a disinfectant, 61 Erysipelas, 173, 230 Eiythema, septic, 230 Esmarch's constriction, 194, 222 Ether, dangers of, 280 discovery of, 268 indications and contraindications for administration of, 270 Etherization, albumen in urine after, 269 Finger-nails, care of, 92 Folding stand. Beck's, no Fractures, compound, dressings in, 235 treatment of, 187 Gall-bladder, open treatment after operation on the, 208 Gangrene of the lips of a wound, 183 Gauze bag, Mikulicz's, 209 disinfection of, 67 shortly before operation, 248 drain, 218. iodoformized. See Iodoform gauze. packing, 198 temporary, 211 preservation of sterilized, 114 Glass drainage-tubes, 141 jars for preserving catgut, 128 shelves in operating-room, 145 Gloves of linen or of rubber dam, 94 Glycerin as a constituent of iodoform, 263 Gonococcus, 39 Granulations of wound-surfaces, 197 Green soap, 92, 96, loi Gunshot wounds, 187 Hairs, shaving of, 97 Hanging drop, examination of, 32 Hard-rubber tubes, 141 Heat as a disinfectant, 63 Hemorrhage after laparotomy, 223 from brain-sinuses, treatment of, 210 secondar)', 220 Hippocratic area, asepsis in the, 58 Hotzen's syringe, 267 Hyperasmia, antitubercular influence of artificial, 258 Hypodermatic injections. See Injec- tions. Hypodermic syringes. See Syringes. Immobilization in wound treat- ment, 122, 168, 195, 200, 252, 261 Immunity, 70 Importance of asepsis, 53 Incubator, 31 Infected wounds, 171 Infection following injection, 253 symptoms of, 178 Inflammation of wound-edges, 180, 232 Inhaler, Braatz's, 274 choice of, 271 Injection dosage of iodoform, 261 fluid, sterility of, 255 Inoculating animals, -^t^ Inoculation by scratching, 49, 70 for curing malignant diseases, 74 of the tubercular bacillus, 258 with putrid fluids, 174 Intestines, iodoform gauze in opera- tions on, 207 Iodoform as a drug, Zt^ as an ethereal solution, 85, 97, 256, 262, 264 collodion, 87, 97 eczema, 226 symptoms of, 227 emulsion, sterilization of, 256 gauze, preparation of, 123 glycerin, 85, 262 idiosyncrasy, 86, 229 oil, 258, 262 suppositories, 87 tul)erculocidal influence of, 257 value of, as an injection, S3, 255 Irrigation fluid, 142 trocar. Beck's, 259 304 INDEX. Irrigator, 136 Isolating microbes, 29 Kelly's (Howard) method of dis- infection, 93 Kidneys, open treatment after opera- tions on, 211 preparations before operations on, 100 Knives, disinfection of, 106 Koch's syiinge, 266 Kiimmel's method of disinfection, 92 Laity, instruction of, in the treat- ment of wounds, 297 Laparotomy, preparation for, 96 Leucocytes, 50 Leucomaines, 26 Ligature-bottle, 133 Linear cultures, 33 Liver, open treatment in operations on, 208 Local anaesthesia, 282 Maxilla-separator, Beck's, 275, 279. . Means of disinfection, 60 Mechanical disinfection, 61, 104 Microbes, cultivation of, 20 influence of, 17 multiplication of, 19 Micrococcus, 22 Micro-organisms in general, 17 Microscopical examinations during operation, 89 Mirrors, sterilization of, 109 Mitigated cultures, 71, 72 Moist blood -clot, Schede's, 142, 159 Moisture in putrid wounds, 198 Morphine injections, 253 Moss board, 122, 195, 252 Moulds. See Fungi. Mouth, disinfection of, loi Mucous membranes, disinfection of, 97 Mycotozoa (protozoa), 17 Necrosis of wound-margins, 230 Needle-point cultures, 2>Z Nose, disinfection of, loi Nurses, 240, 245, 294 Obligate microbes, 31 Occluded wounds, 161 Office, arrangement of surgeon's, 297 Olive oil as a constituent of iodo- form emulsion, 263 Open-wound treatment, 1 86 Operating-room, 143 determining the presence of mi- crobes in, 147 dissemination of microbes in, 146 private, arrangement of, 1 5 1 Operating-suits, 241, 247 Operating-table, 152 Operation, aseptic, technique of, in a hospital, 239, 243 in private practice, 284 Operation-blank, Keen's, 294 Pails, 158 Pain in wounds, 236 Pathogenic microbes, 21, 28 Patient's family, instructions to, be- fore operation, 292 Pelvic organs, treatment after opera- tion on the, 210 Perineal section, treatment after, 214 Peritoneum. See Abdominal cavity. Peroxide of hydrogen, 82 Petri's plates, 33 Phagocytes, 71 Phenol, 76 Phlegmon, 173, 183 Phlogosin, 35, 50 Plastic operations, removal of sutures after, 215 Pneumococcus, Friedlander's, 41 Pocket case for instruments, 290 Pot as a sterilizer, 105, 291 Preparations before operation, 239, 243, 246 in emergencies, 240 for a special operation, 249 Pressure in the treatment of wounds, 233 Primary union, 159, partial, 223 Private rooms, 158 INDEX. 305 Procedures before and during opera- tions, 249 Prophylactic suture, 166 Ptomaines, 26 Pus-retention after suturing, 182, 224 Putrefaction. See Sepsis. Pyeemia, 173 Pyogenic cocci, 36 Pyothorax, bacteriological examina- tion of pus in, 90 Diplococcus pneumonias in, 40 drainage in, 234 Staphylococcus aureus in, 37 treatment in, 212 Pyrozone, 82 Rectum, disinfection of, 98 Reels for silk sutures, 134 Relaxation-sutures, 164 Rubber catheters, sterilization of, 109 drainage-tubes. See Drainage. gloves, 94 Salicylated gauze, 1 24 Salicylic acid, 81 Salol, 100 Saprophytes, 20, 22 Schizomycetes, 17, 18 Schmidt's aseptic syringe, 267 Sepsis, 173 definition of, 17 Septic fever, 170, 179 Septogenic microbes, differentiation of, 176 organisms, 28 Sharp spoon, 205 Silkworm gut, 136 Silver wire, 136 Silver- wire suture, 166 Situation-sutures, 166 Skin, disinfection of, 92, 95 Soap, loi Soda, chemical composition of, 106 Soda-solution, efficiency of, 105 Sounds, disinfection of, 99 Specific contagious diseases, 52 ulcers, 234 Spectators in operating-room, 145 Spirillum, 22 Spirochaete. See Spirillum. 20 Splint, Beck's extractable, for non- united fractures, 236 Sponges, 137 Spores, 62 Staining microbes, 30 Staphylococcus, 24 pyogenes aureus, 35 citreus, 38 Steam as a disinfectant, 63 Sterilization, definition of, 107 of catgut, 125 of drainage-tubes, 139 of silk, 133 of sponges, 137 uncertainty of, 128 Sterilizer, Beck's, 119 Bra'atz's, 1 17 Koch's, 1 1 1 Korte's, 118 Lautenschlager's, 112 Mally's, 117 Schimmelbusch's, 115 Stitches, removal of, 215 Stomach, preparation before opera- tion on, loi Streptobacterium . See Streptococcus pyogenes. Streptococcus pyogenes, 24, 38 Subcutaneous sutures. See Buried sutures. Suits, Beck's sterilized, for patients, 246 sterilized, for surgeons and nurses, 241, 247 Sunlight as a disinfectant, 61 Suppuration, 35 in buried sutures, 182 of stitch-canals, 181, 183 Suprapubic section, treatment after, 214 Suture-cases, 133 Sutures, extraction of, 224, 231 Suturing, technique of, 163 Syringes, hypodeniiic, sterilization of, 265' Tabi-ES for basins, 145 for dressings and instruments, 154 for Trendelenburg's position, 153 Tartaric acid as an addition to bi- chloride, 80 3o6 INDEX. Technique of sponging, 250 of suturing, 163 of uniting wounds, after Neuber, 162 Temperature as a guide in treatment, 236 Tin box, Schimmelbusch's, 114 Tongue-forceps, Beck's, 275 Torula. See Streptococcus. Towels, disinfection of, 248 sterilized, in operation, 250 Toxalbumins, 26 Toxines, 26, 35 Tuberculosis peritonei, treatment of, 261, 265 surgical treatment of, 206 Tuberculous ulcers, 234 Umbilicus, disinfection of, 97 Urethra, disinfection of, 100 Urine, examination of, before opera- tion, 239 microbes in, 99 Vagina, disinfection of, 97 Varicose ulcers, 232 Vibrio. See Spirillum. Von Farkas' steam-atomizer, 98, 108 Wards of a hospital, 158 Water for sterilization, 142 Water-supply in operating-room, 144 Wire splint, Beck's modification, 200 Kramer's, 200 Yeast fungi, 17 ZOOGLCEA, 25 opkl PUBLISHED BY W. B. SAUNDERS, 925 Walnut Street, Philadelphia, Pa. PAGE ♦American Text-Book of Applied Thera- peutics 3 ♦American Text-Book of Diseases of Chil- dren 3 ♦American Text-Book of Gynecology . . 4 ♦American Text-Book of Nursing .... 8 ♦American Text-Book of Obstetrics ... 8 ♦American Text-Book of Physiology ... 8 ♦American Text-Book of Practice .... 2 ♦American Text-Book of Surgery . . . . i Ashton's Obstetrics 23 Ball's Bacteriology 27 Bastin's Laboratory Exercises in Botany . 18 Beck's Surgical Asepsis 14 Brockway's Physics 27 Burr's Nervous Diseases 12 Cerna's Notes on the Newer Remedies . .18 Chapman's Medical Jurisprudence and Toxicology 14 Cohen and Eshner's Diagnosis 26 Cragin's Gynaecology 24 DaCosta's Manual of Surgery 13 ♦De Schweinitz's Diseases of the Eye . . 5 Dorland's Obstetrics 13 Frothingham's Guide to Bacteriological Laboratory 14 Garrigues' Diseases of Women 10 Gleason's Diseases of the Ear 28 Griffin's Materia Medica and Therapeutics 12 ♦Gross's Autobiography 7 Hare's Physiology 22 Hampton's Nursing : its Principles and Practice 15 Hyde's Syphilis and Venereal Diseases . . 12 Jackson and Gleason's Diseases of the Eye, Nose, and Throat 25 Jewett's Outlines of Obstetrics 18 ♦Keating's Pronouncing Dictionary of Medicine 7 Keating's How to Examine for Life In- surance 20 PAGE Keen's Operation Blanks 16 Kyle's Diseases of Nose and Throat ... 12 Laine's Temperature Charts 9 Lockwood's Practice of Medicine .... 12 Long's Syllabus of Gynecology 9 Martin's Surgery 22 Martin's Minor Surgery, Bandaging, and Venereal Diseases 25 Morris' Materia Medica and Therapeutics 23 Morris' Practice of Medicine 24 Morton's Nurses' Dictionary 9 Nancrede's Anatomy and Manual of Dis- section 16 Nancrede's Anatomy 22 Norris' Syllabus of Obstetrical Lectures . 17 Powell's Diseases of Children 26 Raymond's Physiology 13 Saunders' Pocket Medical Formulary . . 19 Saunders' Pocket Medical Lexicon .... 19 Saunders' New Aid Series of Manuals . 11, 12 Saunders' Series of Question Compends . 21 Sayre's Practice of Pharmacy 26 Semple's Pathology and ^lorbid Anatomy 23 Semple's Legal Medicine, Toxicology, and Hygiene 25 Senn's Syllabus of Lectures on Surgery . . 17 Shaw's Nervous Diseases and Insanity . . 27 Stelwagon's Diseases of the Skin .... 24 Stevens' Materia Medica and Therapeu- tics 20 Stevens' Practice of Medicine 17 Stewart and Lawrance's Medical Elec- tricity 28 Thornton's Dose- Book and Manual of Pre- scription-Writing 14 ♦Vierordt and Stuart's Medical Diagno- sis 6 Warren's Surgical Pathology 10 Wilson's Orthopaedic Surgery 15 Wolffs Chemistry 23 Wolff's Examination of Urine 26 Mr. Satjnders, in presenting to the profession the following list of his publications, begs to state that the aim has been to make them worthy of the confidence of medical book-buyers by the high standard of authorship and by the excellence of typography , paper , printing, and binding. 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" A valuable addition to the literature of Gynecology. The writers are progressive, aggressive, and earnest in their convictions." — Medical News, Philadelphia. " A thoroughly modern text-book, and gives reliable and well-tempered advice and in- struction." — Edinburgh Medical Jourtial. "The harmony of its conclusions and the homogeneity of its style give it an individuality which suggests a single rather than a multiple authorship." — A?inals of Surgery. '• It must command attention and respect as a worthy representation of our advanced clinical teaching." — American Journal 0/ Medical Sciences. CATALOGUE OF MEDICAL WORKS. For Sale by Subscription. DISEASES OF THE EYE. A Handbook of Ophthalmic Prac- tice. By G. E. DE SCHWEINITZ, M. D., Professor of Diseases of the Eye, Philadelphia Polyclinic ; Professor of Clinical Ophthalmology, Jefferson Medical College, Philadelphia, etc. Forming a handsome royal-octavo volume of more than 600 pages, with over 200 fine wood-cuts, many of which are original, and 2 chromo-lithographic plates. Prices : Cloth, ^4.00 net; Sheep, $5.00 net: Half Russia, $5.50 net. The object of this work is to present to the student and practitioner who is beginning work in the fields of ophthalmology a plain description of the optical defects and diseases of the eye. To this end special attention has been paid to the clinical side of the question; and the method of examination, the symp- tomatology leading to a diagnosis, and the treatment of the various ocular defects have been brought into special prominence. The general plan of the book is eminently practical. Attention is called to the large number of illustrations (nearly one-third of which are new), which will materially facilitate the thorough understanding of the subject. "For the student and practitioner it is the best single volume at present published." — Medical News, Philadelphia. " A most complete and sterling presentation of the present status of modern knowledge concerning diseases of the eye." — Medical Age. " Pre-eminently a book for those wishing a clear yet comprehensive and full knowledge of the fundamental truths which imderlie and govern the practice of ophthalmology." — Med- ical and Surgical Reporter. "At once comprehensive and thoroughly up to date." — Hospital Gazette (London). PROFESSIONAIi OPINIOXS. " A work that will meet the requirements not only of the specialist, but of the general practitioner in a rare degree. I am satisfied that unusual success awaits it." William Pepper, M. D., Provost and Professor 0/ Theory and Practice of Medicine and Clinical Medicine in the University of Pennsylvania. "Contains in concise and reliable form the accepted views of Ophthalmic Science." William Thomson, M. D., Professor of Ophthalmology, yefferson Medical College, Philadelphia, Pa. " Contains in the most attractive and easily understood form just the sort of knowledge which is necessary to the intelligent practice of general medicine and surgery." J. William White, M. D., Professor of Clinical Surgery in the University of Pennsylvania. "A very reliable guide to the study of eye diseases, presenting the latest facts and newest ideas." Swan M. Burnett, M. D., Professor of Ophthalmology and Otology, Medical Depart tnent Univ. of Georgetown, IVashington, D. C. fV. B. SAUNDERS' For Sale by Subscription. MEDICAL DIAGNOSIS. By Dr. Oswald Vierordt, Professor of Medicine at the University of Heidelberg. Translated, with additions, from the Second Enlarged German Edition, with the author's permission, by Francis H. Stuart, A. M., M. D. Third and Revised Edition. In one handsome royal-octavo volume of 700 pages, 178 fine wood-cuts in text, many of which are in colors Prices : Cloth, $4.00 net; Sheep, ^5.00 net ; Half Russia, ^5.50 net. In this work, as in no other hitherto published, are given full and accurate explanations of the phenomena observed at the bedside. It is distinctly a clin- ical work by a master teacher, characterized by thoroughness, fulness, and accu- racy. It is a mine of information upon the points that are so often passed over without explanation. Especial attention has been given to the germ-theory as a factor in the origin of disease. This valuable work is now published in German, English, Russian, and Italian. The issue of a third American edition within two years indicates the favor with which it has been received by the profession. " Rarely is a book published with which a reviewer can find so little fault as with the volume before us. All the chapters are full, and leave little to be desired by the reader. Each particular item in the consideration of an organ or apparatus, which is necessary to determine a diagnosis of any disease of that organ, is mentioned ; nothing seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and nervous system are especially full and valuable. Notwithstanding a few minor errors in translating, which are of small importance to the accuracy of the rest of the volume, the reviewer would repeat that the book is one of the best— probably the best — which has fallen into his hands. An excel- lent and comprehensive index of nearly one hundred pages closes the volume." — University Medical Magazine, Philadelphia. " Thorough and exact The author has rendered no mean service to medicine in having prepared a work which proves as useful to the teacher as to the student and prac- titioner." — The Lancet (London). , PROFESSIONAI4 OPINIONS. "One of the most valuable and useful works in medical literature." Aleicander J. C. Skene, M. D., Dean 0/ the Long Island College Hospital, and Professor of the Medical and Surgical Diseases of Wotnen. " Indispensable to both ' students and practitioners.' " F. MiNOT, M. D., Hersey Professor of Theory and Practice of Medicine , Harvard University. " It is very well arranged and very complete, and contains valuable features not usually found in the ordinary books." J. H. MussER, M. D., Assistant Professor Clinical Medicine, University of Pennsylvania. " One of the most valuable works now before the profession, both for study and reference." N. S. Davis, M. D., Professor of Principles and Practice of Medicine and Clinical Medicine, Chicagg Medical College. CATALOGUE OF MEDICAL WORKS. For Sale by Subscription. A NEW PRONOUNCING DICTIONARY OF MEDICINE, with Phonetic Pronunciation, Accentuation, Etymology, etc. By John M. Keating, M. D., LL.D., Fellow of the College of Physicians of Phila- delphia; Vice-President of the American Paediatric Society; Ex-President of the Association of Life Insurance Medical Directors ; Editor " Cyclo- paedia of the Diseases of Children," etc.; and Henry Hamilton, author of "A New Translation of Virgil's ^neid into English Rhyme;" co- author of "Saunders' Medical Lexicon," etc.; with the Collaboration of J. Chalmers DaCosta, M. D., and Frederick A. Packard, M. D. With an Appendix containing important Tables of Bacilli, Micrococci, Leucomaines, Ptomaines, Drugs and Materials used in Antiseptic Sur- gery, Poisons and their Antidotes, Weights and Measures, Thermometric Scales, New Ofificial and Unofficial Drugs, etc. Forming one very attractive volume of over 800 pages. Second Revised Edition. Prices : Cloth, ^5.00 net; Sheep, $6.00 net; Half Russia, ^6.50 net. With Denison's Patent Index for Ready Reference. PROFESSIONAL. OPINIONS. " I am much pleased with Keating's Dictionary, and shall take pleasure iu recommending it to my classes." Henkv M. Lyman, M. D.. Professor of Principles and Practice of Medicine, Rush Medical College, Chicago, III. " I am convinced that it will be a very valuable adjunct to my study-table, convenient in size and sufficiently full for ordinary use." C. A. LiNDSLEY, M. D., Professor of Theory and Practice of Medicine, Aledical Dept. Yale University : Secretary Connecticut State Board of Health, New Haven, Conn. "I will point out to my classes the many good features of this book as compared with others, which will, I am sure, make it very popular with students." John Cronyn, M. D., LL.D., Professor of Principles and Practice of Medicitie and Clinical Medicine ; President of the Faculty, Medical Dept. Niagara University, Buffalo, N. Y. AUTOBIOGRAPHY OF SAMUEL D. GROSS, M. D., Emeritus Pro- fessor of Surgery in the Jefferson Medical College of Philadelphia, with Reminiscences of His Times and Contemporaries. Edited by his sons, Samuel V/. Gross, M. D., LL.D., late Professor of Principles of Surgery and of Clinical Surgery in the Jefferson Medical College, and A. Haller Gross, A. M., of the Philadelphia Bar. Preceded by a Memoir of Dr. Gross, by the late Austin Flint, AL D., LL.D. In two handsome volumes, each containing over 400 pages, demy 8vo, extra cloth, gilt tops, with fine F>ontispiece engraved on steel. Price, $5.00 net. This autobiography, which was continued by the late eminent surgeon until within three months of his death, contains a full and accurate history of his early struggles, trials, and subsequent successes, told in a singularly interesting and charming manner, and embraces short and graphic pen-portraits of many of the most distinguished men — surgeons, physicians, divines, lawyers, states- men, scientists, etc. — with whom he was brought in contact in America and in Europe ; the whole forming a retrospect of more than three-quarters of a century. W. B. SAUNDERS' For Sale by Subscription. AN AMERICAN TEXT-BOOK OF OBSTETRICS. By American Teachers. By Richard C. Norris, A. M., M. D.; James H. Etheridge, M. D. ; Chauncey D. Palmer. M. D. ; Howard A. Kelly, M. D. ; Charles Jewett, M. D. ; Henry J. Garrigues, M. D. ; Barton Cooke Hirst, M. D. ; Theophilus Parvin, M. D. ; George A. Piersol, M. D. ; Edward P. Davis, M. D. ; Charles Warrington Earle, M. D. ; Robert L. Dickinson, M. D. ; Edward Reynolds, M. D. ; Henry Schwarz, M. D. ; and James C. Cam- eron, M. D. In one very handsome imperial- octavo volume, with a large number of original illustrations, including full-page plates, and uniform with " The American Text-Book of Gynecology." (In active preparation.) Such an array of well-known teachers is a sufficient guarantee of the high character of the work, and it gives the assurance that this work will have the same measure of success awarded it as has attended the recent publication of its companion volume, " The American Text-Book of Gynecology." The illus- trations will receive the most minute attention ; the cuts interspersed throughout the text, and the full-page plates, which will reflect the highest attainments of the artist and engraver, will appeal at once to the eye as well as to the mind of the student and practitioner. AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. By American Teachers. Edited by William H. Howell, Ph. D., INI. D., Professor, of Physiology, Johns Hopkins University. With the collaboration of such eminent specialists as Henry P. Bowditch, M. D. ; John G. Curtis, M. D. ; Henry H. Donaldson, M. D. ; Frederick S. Lee, M. D. ; Warren P. Lom- bard, A. B., M. D. ; Graham Lusk, Ph. D. ; Henry Sewall, M. D. ; Edward T. Reichert, M. D. ; Joseph W. Warren, M. D. In one imperial-octavo volume (with a large number of original illustrations), \iniform with The American Text-Books of " Surgery," " Practice," " Gynecology," etc. (In preparation for early publication.) This will be the most notable attempt yet made in this country to combine in one volume the entire subject of Human Physiology by well-known teachers who have given especial study to that part of the subject upon which they will write. The completed work will represent the present status of the science of Physiology, and in particular from the standpoint of the student of medicine and the medical practitioner. Illustrations largely drawn from original sources will be used freely throughout the text. AN AMERICAN TEXT-BOOK OF APPLIED THERAPEUTICS. By American Teachers. (In preparation.) AN AMERICAN TEXT-BOOK OF NURSING. By American Teachers. (In preparation.) CATALOGUE OF MEDICAL WORKS. A SYLLABUS OF GYNiECOLOGY, arranged in conformity with The American Text-Book of Gynecology. By J. W. Long, M. D., Professor of Diseases of Women and Children, Medical College of Vir- ginia, etc. Price, Cloth (interleaved), ^i.oo net. Based upon the teaching and methods laid down in the larger work, this will not only be useful as a supplementary volume, but to those who do not already possess the text-book it will also have an independent value as an aid to the practitioner in gynecological work, and to the student as a guide in the lecture- room, as the subject is presented in a manner at once systematic, clear, succinct, and practical. TEMPERATURE CHART. Prepared by D. T. Laine, M. D. Size 8x 13 j^ inches. Price, per pad of 25 charts, 50 cents. A conveniently arranged chart for recording Temperature, with columns for daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On the back of each chart is given in full the method of Brand in the treatment of Typhoid Fever. THE NURSE'S DICTIONARY of Medical Terms and Nursing Treatment, containing Definitions of the Principal Medical and Nursing Terms, Abbreviations, and Physiological Names, and Descriptions of the Instruments, Drugs, Diseases, Accidents, Treatments, Operations, Foods, Appliances, etc. encountered in the ward or in the sick-room. Compiled for the use of nurses. By HoNNOR Morten, author of " How to Become a Nurse," " Sketches of Hospital Life," etc. Second and enlarged edi- tion. i6mo, 140 pages. Price, Cloth, $1.00. This little volume is intended for use merely as a small reference-book which can be consulted at the bedside or in the ward. It gives sufficient explanation to the nurse to enable her to comprehend a case until she has leisure to look up larger and fuller works on the subject. "Should be at the disposal of every nurse." — Birmingham Medical Review. "Maintains its reputation for brevity and simplicity." — Hahnetizannian Monthly. "Though ostensibly for professional nurses, contains in a compact form just such infor- mation as almost every intelligent man would like to have at hand in these days when the interest in all matters of sanitation and medicine has become so great." — Medical Examiner. " A book which every progressive nurse must have." — Medical IVorld. " This little volume is almost indispensable in the training school and in the library of the nurse." — New York Medical Times. 10 W. B. SAUNDERS' SURGICAL PATHOLOGY AND THERAPEUTICS. By J. Col- lins Warren, M. D., Professor of Surgery, Harvard Medical School, etc. In one very handsome octavo volume of over 800 pages, with 135 illus- trations, 2)3 of which are chromo-lithographs, and all of which are drawn from original specimens. Prices: Cloth, ^6.00 net ; Half Morocco, $7.00 net. Sold by subscription. Covering as it does the entire field of Surgical Pathology and Surgical Thera- peutics by an acknowledged authority, the publisher is confident that the work will rank as a standard authority on the subject of which it treats. Particular attention has been paid to Bacteriology and Surgical Bacteria from the stand- point of recent investigations, and the chromo-lithographic plates in their fidelity to nature and in scientific accuracy have hitherto been unapproached. DISEASES OF WOMEN. By Henry J. Garrigues, A.M., M.D., Professor of Obstetrics in the New York Post-Graduate Medical School and Hospital; -Gynecologist to St. Mark's Hospital and to the German Dispensary, etc., New York City. In one very handsome octavo volume of about 700 pages, illustrated by numerous wood-cuts and colored plates. Prices: Cloth, $4.00 net; Sheep, ^5.00 net. A practical work on gynecology for the use of students and practitioners, written in a terse and concise manner. The importance of a thorough know- ledge of the anatomy of the female pelvic organs has been fully recognized by the author, and considerable space has been devoted to the subject. The chap- ters on Operations and on Treatment are thoroughly modern, and are based upon the lai'ge hospital and private practice of the author. The text is eluci- dated by a large number of illustrations and colored plates, many of them being original, and forming a complete atlas for studying emb^'yology and the anatomy of \.h.Q fe?nale genitalia, besides exemplifying, whenever needed, morbid condi- tions, instruments, apparatus, and operations. EXCERPT OF COJTTENTS. Development of the Female Genitals.— Anatomy of the Female Pelvic Organs.— Phys- iology.— Puberty.— Menstruation and Ovulation.— Copulation.— Fecundation.— The Climac- teric. — Etiology in General. — Examinations in General. — Treatment in General — Abnormal Menstruation and Metrorrhagia. — Leucorrhea. — Diseases of the Vulva. — Diseases of the Perineum. — Diseases of the Vagina. — Diseases of the Uterus. — Diseases of the Fallopian Tubes. — Diseases of the Ovaries. — Diseases of the Pelvis. — Sterility. The reception accorded to this work has been most flattering. In the short period which has elapsed since its issue it has been adopted and recommended as a text-book by more than 60 of the Medical Schools and Universities of the United States and Canada. "One of the best text-books for students and practitioners which has been puhlished in the English language; it is condensed, clear, and comprehensive. The profound learning and great clinical experience of the distinguished aiuhor find expression in this book in a most attractive and instructive form. Young practitioners, to whom experienced consultants -niay not be available, will find in this book invaluable counsel and help." Thad. a. Reamy, M. D., LL.D., Professor 0/ Clinical Gynecology , Medical CoUef^e of Ohio ; Gynecologist to the Good Samaritan and Cincinnati Hospitals. Practical, Exhaustive, Autl)oritative. SAUNDERS' NEW AID SERIES OF MANUALS FOR Students and Practitioners. Mr. Saunders is pleased to announce as in active preparation his NEW AID SERIES OF MANUALS for Students and Practitioners. As publisher of the Standard Series of Question Compends, and through in- timate relations with leading members of the medical profession, Mr. Saunders has been enabled to study progressively the essential desiderata in practical "self-helps" for students and physicians. This study has manifested that, while the published " Question Compends" earn the highest appreciation of students, whom they serve in reviewing their studies preparatory to examination, there is special need of thoroughly reliable handbooks on the leading branches of Medicine and Surgery, each subject being compactly and authoritatively written, and exhaustive in detail, without the introduction of cases and foreign subject-matter which so largely expand ordinary text-books. The Saunders Aid Series will not merely be condensations from present literature, but will be ably written by well-known authors and practitioners, most of them being teachers in representative American Colleges. This nero series^ therefore, will form an admirable collection of advanced lectures, which will be invaluable aids to students in reading and in comprehending the contents of " recommended " works. Each Manual will further be distinguished by the beauty of the new type ; by the quality of the paper and printing; by the copious use of illustrations; by the attractive binding in cloth ; and by the extremely low price, which will uniformly be $1.25 per volume. II SAUNDERS' NEW AID SERIES OF MANUALS. VOLUMES NOW EEADY. PHYSIOLOGY. By Joseph Howard Raymond, A.M., M. D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital, etc. Price, ^1.25 net. SURGERY, General and Operative. By John Chalmers DaCosta, M. D,, Demonstrator of Surgery, Jefferson Medical College, Philadelphia, etc. Double number. Price, $2.50 net. DOSE-BOOK AND MANUAL OF PRESCRIPTION-WRITING. By E. Q. Thornton, M. D., Demonstrator of Therapeutics, Jefferson Medical College, Philadelphia, Price, ^1.25 net. MEDICAL JURISPRUDENCE. By Henry C. Chapman, M. D., Pro- fessor of Institutes of Medicine and Medical Jurisprudence in the Jeffer- son Medical College of Philadelphia, etc. Price, ^1.25 net. SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and to the German Poliklinik ; Instructor in Surgery, New York Post-Graduate Medical School, etc. Price, $1.25 net. VOLUMES IN PEEPAEATION FOR EAELY PUBLICATION. OBSTETRICS. By W. A. Newman Dorland, M. D., Demonstrator of Obstetrics, University of Pennsylvania; Chief of Gynecological Dispen- sary, Pennsylvania Hospital ; Member of Philadelphia Obstetrical Society, etc. Price, ^1.25 net. MATERIA MEDICA AND THERAPEUTICS. By Henry A. Griffin, A. B., M. D., Assistant Physician to tlie Roosevelt Hospital, Out-patient Department, New York City. Price, ^1.25 net. SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M. D., Professor of Skin and Venereal Diseases in Rush Medical College, Chicago. Double number. Price, ^2.50 net. NERVOUS DISEASES. By Charles W. Burr, M. D., Clinical Pro- fessor of Nervous Diseases, Medico-Chirurgical College, Philadelphia, etc. Price, ^1.25 net. PRACTICE OF MEDICINE. By George Roe Lockwood, M. D., Professor of Practice in the Woman's Medical College and in the New York Infirmary, etc. Double number. Price, $2.50 net. NOSE AND THROAT. By D. Braden Kyle, M. D., Chief Laryngol- ogist to St. Agnes' Hospital, Philadelphia; Instructor in Clinical Micros- copy and Assistant Demonstrator of Pathology in the Jefferson Medical College, etc. Price, ^1.25 net. *.,.* There will be published in the same series, at close intervals, carefully-pre- pared works on the subjects of Anatomy, Gynecology, Pathology, Hygiene, etc., by prominent specialists. 12 CATALOGUE OF MEDICAL WORKS. 1 3 Saunders' New Aid Series of Manuals, A MANUAL OF PHYSIOLOGY. By Joseph H. Raymond, A. M., M.D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital ; Director of Physiology in the Hoag- land Laboratory; formerly Lecturer on Physiology and Hygiene in the Brooklyn Normal School for Physical Education; Ex-Vice-President of the American Public Health Association ; Ex-Health Commissioner City of Brooklyn, etc. Illustrated. Price, Cloth, $1.25 net. (Just ready.) In this manual the author has endeavored to put into a concrete and avail- able form the results of twenty years' experience as a teacher of Physiology to medical students, and has produced a work for the student and practitioner, representing in a concise fomi the existing state of Physiology and its methods of investigation, based upon Comparative and Pathological Anatomy, Clinical Medicine, Physics, and Chemistry, as well as upon experimental research. MANUAL OF SURGERY, General and Operative. By John Chalmers DaCosta, M. D., Demonstrator of Surgery, Jefferson Medical College, Philadelphia; Chief Assistant Surgeon, JeiTerson Medical College Hospital ; Surgical Registrar, Philadelphia Hospital, etc. One very hand- some volume of over 700 pages, with a large number of illustrations. (Double number.) Price, Cloth, ^2.50 net. A new manual of the Principles and Practice of Surgery, intended to meet the demands of students and working practitioners for a medium-sized work which w411 embody all the newer methods of procedure detailed in the larger text-books. The work has been written in a concise, practical manner, and especial attention has been given to the most recent methods of treatment. Illustrations are freely used to elucidate the text. A MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M. D., Demonstrator of Obstetrics, University of Pennsylvania; Chief of Gynecological Dispensary, Pennsylvania Hospital ; Member of Phila- delphia Obstetrical Society, etc. Profusely illustrated. Price, Cloth^ ^1.25 net. (Preparing.) This work, which is thoroughly practical in its teachings, is intended, as its title implies, to be a working text-book for the student and of value to the practitioner as a convenient handbook of reference. Although concisely writ- ten, nothing of importance is omitted that will give a clear and succinct know- ledge of the subject as it stands to-day. Illustrations are freely used throughout the text. 14 W. B. SAUNDERS' Saunders' JVeiv Aid Series of Manuals, DOSE-BOOK AND MANUAL OF PRESCRIPTION-WRITING. By E. Q. Thornton, M. D., Demonstrator of Therapeutics, Jefferson Medical College, Philadelphia. Illustrated. Price, Cloth, $1.25 net. But little attention is generally given, in works on Materia Medica and Thera- peutics, to the methods of combining remedies in the form of prescriptions, and this manual has been written especially for students in the hope that it may sen-e to give a thorough and comprehensive knowledge of the subject. The work, which is based upon the last (1890) edition of the Pharmacopceia, fully covers the subjects of Weights and Measures, Prescriptions (form of writing, general directions to pharmacist, grammatical construction, etc.), Dosage, Incompatibles, Poisons, etc. MEDICAL JURISPRUDENCE AND TOXICOLOGY. By Henry C. Chapman, M. D., Professor of Institutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Philadelphia ; Member of the College of Physicians of Philadelphia, of the Academy of Natural Sciences of Philadelphia, of the American Philosophical Society, and of the Zoological Society of Philadelphia. 232 pages, with 36 illustrations, some of which are in colors. Price, ^1.25 net. For many years there has been a demand from members of the medical and legal professions for a medium-sized work on this most important branch of medicine. The necessarily proscribed limits of the work permit the considera- tion only of those parts of this extensive subject which the experience of the author as coroner's physician of the city of Philadelphia for a period of six years leads him to regard as the most material for practical purposes. Particular attention is drawn to the illustrations, many being produced in colors, thus conveying to the layman a far clearer idea of the more intricate cases. SURGICAL ASEPSIS. By Carl Beck, M. D., Surgeon to St. Mark's Hospital and to the New York German Polikhnik, etc. Price, Cloth, $1.25 net. A practical work for the study of the principles of Surgical Asepsis. Hand- somely embellished with nearly loo graphic representations of methods and appliances. A GUIDE TO THE BACTERIOLOGICAL LABORATORY. By Langdon Frothin(;ham, M.D. Illustrated. Price, 75 cents. The technical methods involved in bacteria-culture, methods of staining, and microscopical study are fully described and arranged as simply and concisely as possible. The book is especially intended for u.se in laboratory work. CATALOGUE OF MEDICAL WORKS. 1 5 NURSING: ITS PRINCIPLES AND PRACTICE. By Isabel Adams Hampton, Graduate of the New York Training School for Nurses attached to Bellevue Hospital ; Superintendent of Nurses and Principal of the Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md. ; late Superintendent of Nurses, Illinois Training School for Nurses, Chicago, 111. In one very handsome i2mo volume of 484 pages, profusely illustrated. Price, Cloth, $2.00 net. This entirely new work on the important subject of nursing is at once com- prehensive and systematic. It is written in a clear, accurate, and readable style, suitable alike to the student and the lay reader. Such a work has long been a desideratum with those intrusted with the management of hospitals and the instruction of nurses in training schools. It is also of especial value to the graduated nurse who desires to acquire a practical working knowledge of the care of the sick and the hygiene of the sick-room. The author, who has had considerable experience as superintendent of training schools for nurses and hospital management, bnngs to her task a mind thoroughly equipped to make the subject attractive as well as scientific and instructive. Thoroughly attested and approved processes in practical nursing only have been given, particularly in antiseptic surgery, and the minutest details regard- ing the nurse's technique have been explained. Illustrations to elucidate the text have been used freely throughout the book, and they will be found of material help m showing the forms of modern appli- ances for the hospital ward and sick-room, the registration of temperature, daily records, etc. METHODS OF PREVENTING AND CORRECTING DEFORM- ITIES OF THE BONES AND JOINTS : A Handbook of Prac- tical Orthopedic Surgery. By H. Augustus Wilson, M. D , Professor of General and Orthopedic Surgery, Philadelphia Polyclinic ; Clinical Pro- fessor of Orthopedic Surgery, Jefferson Medical College, Philadelphia, etc. (In preparation.) The aim of the author is to provide a book of moderate size, containing comprehensive details that will enable general practitioners to understand thor- oughly the mechanical features of the many forms of congenital and acquired deformities of the bones and joints. The mechanical functions that are impaired will be considered first as to pre- vention as of primary importance, and following this will be described the methods of correction that have been proved practical by the author. Ope- rative procedures will be considered from a mechanical as well as a surgical standpoint. Prominence will be given to the mechanical requirements for braces and artificial limbs, etc., with description of the methods for construct- ing the simplest forms, whether made of plaster of Paris, felt, leather, paper, steel, or other materials, together with the methods of readjustment to suit the changes occurring during the progress of the case. A very large number of original illustrations will be used. 1 6 IV. B. SAUNDERS' AN OPERATION BLANK, with Lists of Instruments, etc. re- quired in Various Operations. Prepared by W. W. Keen, M. D., LL.D., Professor of Principles of Surgery in the Jefferson Medical Col- lege, Philadelphia. Price per Pad, containing Blanks for fifty operations, 50 cents net. A convenient blank, suitable for all operations, giving complete instructions regarding necessary preparation of patient, etc., with a full list of dressings and medicines to be employed. At the back of pad is a list of instruments used — viz. general instruments, etc., required for all operations; and special nistruments for surgery of the brain and spme, mouth and throat, abdomen, rectum, male and female genito- urinary organs, the bones, etc. The whole forming a neat pad, arranged for hanging on the wall of a sur- geon's office or in the hospital operatmg-room. " Will serve a useful purpose for the surgeon in reminding him of the details of prepa- ration for the patient and the room as well as for the instruments, dressings, and antiseptics needed " — Ne-jj York Medical Record " Covers about all that can be needed in any operation." — American Lancet. " The plan is Si capital one."— Bosion Medical and Surgical Journal. ESSENTIALS OF ANATOMY AND MANUAL OF PRACTI- CAL DISSECTION, containing " Hints on Dissection " By Charles B. Nancrede, M. D., Professor of Surgery and Clinical Surgery in the University of Michigan, Ann Arbor; Corresponding Member of the Royal Academy of Medicine, Rome, Italy; late Surgeon Jefferson Medical Col- lege, etc. Fourth and revised edition. Post 8vo, over 500 pages, with handsome full-page lithographic plates in colors, and over 200 illustrations. Price : Extra Cloth or Oilcloth for the dissection-room, $2.00 net. Neither pains nor expense has been spared to make this work the most ex- haustive yet concise Student's Manual of Anatomy and Dissection ever pub- lished, either in America or in Europe. The colored plates are designed to aid the student in dissecting the muscles, arteries, veins, and nerves. The wood-cuts have all been specially drawn and engraved, and an Appendix added containing 60 illustrations representing the structure of the entire human skeleton, the whole being based on the eleventh edition of Gray's Anatomy^ and forming a handsome post 8vo volume of over 500 pages. " The plates are of more than ordinary excellence, and are of especial value to students in their work in the C^\'T,'=,itz\\x\%-xouxv\"— Journal of American Medical Association. " Should be in the hands of every medical student." — Cleveland Medical Gazette. " A concise and judicious ^oxV."— Buffalo Medical and Surgical Journal. CATALOGUE OF MEDICAL WORKS. 1/ A MANUAL OF PRACTICE OF MEDICINE. By A. A. Stevens, A. M,, M. D., Instructor of Physical Diagnosis in the University of Penn- sylvania, and Demonstrator of Pathology in the Woman's Medical College of Philadelphia. Specially intended for students preparing for graduation and hospital examinations, and includes the following sections : General Diseases, Diseases of the Digestive Organs, Diseases of the Respirator)' System, Diseases of the Circulatory System, Diseases of the Nervous Sys- tem, Diseases of the Blood, Diseases of the Kidneys, and Diseases of the Skin. Each section is prefaced by a chapter on General Symptomatology. Third edition. Post 8vo, 502 pages. Numerous illustrations and selected formulae. Price, ^2.50. Contributions to the science of medicine have poured in so rapidly during the ^ast quarter of a century that it is well-nigh impossible for the student, with the limited time at his disposal, to master elaborate treatises or to cull from them that knowledge which is absolutely essential. From an extended experience in teaching, the author has been enabled, by classification, to group allied symp- toms, and by the judicious elimination of theories and redundant explanations to bring within a comparatively small compass a complete outline of the prac- tice of medicine. A SYLLABUS OF LECTURES ON THE PRACTICE OF SUR- GERY, arranged in conformity with The American Text-Book of Surgery. By Nicholas Senn, M. D., Ph. D., Professor of Surgery in Rush Medical College, Chicago, and in the Chicago Polyclinic. Price, ^2.00. This, the latest work of its eminent author, himself one of the contributors to the " American Text- Book of Surgery," will prove of exceptional value to the advanced student who has adopted that work as his text-book. It is not only the syllabus of an unrivalled course of surgical practice, but it is also an epitome or supplement to the larger work. SYLLABUS OF OBSTETRICAL LECTURES in the Medical Department, University of Pennsylvania. By Richard C. Norris, A. M., M. D., Demonstrator of Obstetrics in the University of Pennsyl- vania. Third edition, thoroughly revised and enlarged. Crown 8vo. Price, Cloth, interleaved for notes, $2.00 net. "This work is so far superior to others on the same subject that we take pleasure in call- ing attention briefly to its excellent features. It covers the subject thoroughly, and will prove invaluable both to the student and the practitioner. The author has introduced a number of valuable hints which would only occur to one who was himself an experienced teacher of obstetrics. The subject-matter is clear, forcible, and modern. We are especially pleased with the portion devoted to the practical duties of the accoucheur, care of the child, etc. The paragraphs on antiseptics are admirable; there is no doubtful tone in the direc- tions given. No details are regarded as unimportant; no minor matters omitted. We ven- ture to say that even the old practitioner will find useful hints in this direction which he can- not afford to despise." — Neiv York Medical Record. 1 8 W. B. SAUNDERS' OUTLINES OF OBSTETRICS : A Syllabus of Lectures Deliv- ered at Long Island College Hospital. By Charles Jewett, A. M,, M. D., Professor of Obstetrics and Pediatrics in the College, and Obstetri- cian to the Hospital. Edited by Harold F. Jewett, jSI. D. Post 8vo, 264 pages. Price, $2.00. This book treats only of. the general facts and principles of obstetrics : these are stated in concise terms and in a systematic and natural order of sequence, theoretical discussion being as far as possible avoided; the subject is thus presented in a form most easily grasped and remembered by the student. Special attention has been devoted to practical questions of diagnosis and treatment, and in general particular prominence is given to facts which the stu- dent most needs to know. The condensed form of statement and the orderly arrangement of topics adapt it to the wants of the busy practitioner as a means of refreshing his knowledge of the subject and as a handy manual for daily reference. NOTES ON THE NEWER REMEDIES: their Therapeutic Ap- plications and Modes of Administration. By David Cerna, M. D., Ph. D., Demonstrator of and Lecturer on Experimental Therapeutics in the University of Pennsylvania. Post-octavo, 253 pages. Price, ^1.25. The work takes up in alphabetical order all the newer remedies, giving their physical properties, solubility, therapeutic applications, administration, and chemical formula. It thus forms a very valuable addition to the various works on therapeutics now in existence. Chemists are so multiplying compounds, that, if each compound is to be thor- oughly studied, investigations must be carried far enough to determine the prac- tical importance of the new agents. " Especially valuable because of its completeness, its accuracy, its systematic consider- ation of the properties and therapy of many remedies of which doctors generally know but little, expressed in a brief yet terse manner." — Chicago Clinical Review. " A timely and needful book .... which physicians who avail themselves of the use of the newer remedies cannot afford to do without." — The Sanitarian. LABORATORY EXERCISES IN BOTANY. By Edson S. Bastin, M. A., Professor of Materia Medica and Botany in the Philadelphia Col- lege of Pharmacy. Octavo volume of 540 pages, 87 full-page plates. Price, Cloth, $2.50. This work is intended for the beginner and the advanced student, and it fully covers the structure of flowering plants, roots, ordinary stems, rhizomes, tubers, bulbs, leaves, flowers, fruits, and seeds. Particular attention is given to the gross and microscopical structure of plants, and to those used in medicine. Illustra- tions have freely been used to elucidate the text, and a complete index to facil- itate reference has been added. CATALOGUE OF MEDICAL WORKS. 1 9 SAUNDERS' POCKET MEDICAL LEXICON; or, Dictionary of Terms and Words used in Medicine and Surgery. By John M. Keating, M. D., editor of "Cyclopaedia of Diseases of Children," eic. ; author of the " New Pronouncing Dictionaiy of Medicine; and Henry Hamilton, author of " A New Translation of Virgil's ^neid into Eng- lish Verse;" co-author of a " New Pronouncing Dictionary of Medicine." A new and revised edition. 32nio, 282 pages. Prices: Cloth, 75 cents; Leather Tucks, $1.00. This new and comprehensive work of reference is the outcome of a demand for a more modern handbook of its class than those at present on the market, which, dating as they do from 1855 to 1884, are-of but trifling use to the student by their not containing the hundreds of new words now used in current litera- ture, especially those relating to Electricity and Bacteriology, " Remarkably accurate in terminology, accentuation, and ^^'nu\i\on."— Journal of Amer- ican Medical Association. "Brief, yet complete .... it contains the very late.st nomenclature in even the newest departments of medicine." — Neiv York Medical Record. SAUNDERS' POCKET MEDICAL FORMULARY. By William M. Powell, M. D., Attending Physician to the Mercer House for Invalid Women at Atlantic City. Containing 1750 Formulse, selected from several hundred of the be.st known authorities. Forming a handsome and con- venient pocket companion of nearly 300 printed pages, with blank leaves for Additions; with an Appendix containing Posological Table, Formulse and Doses for Hypodermatic Medication, Poisons and their Antidotes, Diameters of the Pemale Pelvis and Foetal Head, Obstetrical Table, Diet List for Various Diseases, Materials and Drugs used in Antiseptic Surgerj', Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Third edition, revised and greatly enlarged. Handsomely bound in morocco, with side index, wallet, and flap. Price, $1.75 net. A concise, clear, and correct record of the many hundreds of famous formulse which are found scattered through the works of the most etninent physicians and surgeons of the world. The work is helpful to the student and practitioner alike, as through it they become acquainted with numerous formulae which are not found in text-books, but have been collected from among the rising genera- tion of the profession, college professors, and hospital physicians and siageons. "This little book, that can be conveniently carried in the pocket, contains an imrnense amount of material. It is very useful, and as the name of the author of each prescription is given is unusually reliable." — New York Medical Record. " Designed to be of immense help to the general practitioner in the exercise of his daily calling." — Boston Medical and Surgical yournal. 20 W. B. SAUNDERS' HOW TO EXAMINE FOR LIFE INSURANCE. By John M. Keating, M. D., Fellow of the College of Physicians and Surgeons of Philadelphia; Vice-President of the American Pajdiatric Society; Ex- President of the i\ssociation of Life Insurance Medical Directors. Royal 8vo, 211 pages, with two large phototype illustrations, and a plate pre-_ pared by Dr. McClellan from special dissections ; also, numerous cuts to elucidate the text. Second edition. Price, in Cloth, $2.00 net. Part I., which has been carefully prepared from the best works on Physical Diagnosis, is a short and succinct account of the methods used to make examinations ; a description of thp normal condition and of the earliest evidences of disease. Part II. contains the Instructions of twenty-four Life Insurance Companies to their medical examiners. " This is by far the most useful book which has yet appeared on insurance examination, a subject of growing interest and importance. Not the least valuable portion of the volume is Part II., which consists of instructions issued to their examining physicians by twent)'-four representative companies of this country. As the proofs of these instructions were corrected by the directors of the companies, they form the latest instructions obtainable. If for these alone, the book should be at the right hand of every physician interested in this special branch of medical science." — The Medical News, Philadelphia. MANUAL OF MATERIA MEDICA AND THERAPEUTICS. By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the University of Pennsylvania, and Demonstrator of Pathology in the Woman's Medical College of Philadelphia. 435 pages. Price, Cloth, ^2.25. This wholly new volume, which is based on the 1890 edition of the Pharma- copoeia, comprehends the following sections : Physiological Aciion of Drugs ; Drugs; Remedial Measures other than Drugs; Applied Therapeutics; Incom- patibility in Prescriptions; Table of Doses; Index of Drugs; and Index of Diseases; the treatment being elucidated by more than two hundred formulge. "The author is to be congratulated upon having presented the medical student with as accurate a manual of therapeutics as it is possible to prepare."— 7%^r«/^«2'/<: (gazette. " Far superior to most of its class ; in fact, it is very good. Moreover, the book is reliable and accurate." — New York Medical Jour 77 al . "The author has faithfully presented modern therapeutics in a comprehensive work. . . . and it will be found a reliable g\i\d&."—U7ti7>ersity Medical Magai.inr. "Will be of immense service to the busy ^^x'3.c\:\\:\ow&x." —Medical Reporter (Calcutta). " Reliable and ^\mt^y ." — North American Practitioner. "Concise, up to date, and withal comprehensive."— /'«cz/?^ Medical Journal. SAUNDERS' QUESTION COMPENDS. Arranged in Question and Answer Form. THE LATEST, CHEAPEST, and BEST ILLUSTEATED SEEIES OF COMPENLS EVER ISSUED. Now the Standard Authorities in Medical Literature students and Practitioners in every City of the United States and Canada. THE REASON \VHY. They are the advance guard of " Student's Helps " — that DO help; they are the leaders in their special line, well and authoritatively written by able men, who, as teachers in the large colleges, know exactly ivhat is wanted by a student preparing for his exafninations. The judgment exercised in the selection of authors is fully demonstrated by their professional elevation. Chosen from the ranks of ^Demonstrators, Quiz-masters, and Assistants, most of them have be- come Professors and Lecturers in their respective colleges. Each book is of convenient size (5x7 inches), containing on an average 250 pages, profusely illustrated, and elegantly printed in clear, readable t}'pe, on fine paper. The entire series, numbering twenty- four subjects, has been kept thoroughly revised and enlarged when necessaiy, many of them being in their fourth and fifth editions. TO SUM UP. Although there are numerous other Quizzes, Manuals, Aids, etc. in the mar- ket, none of them approach the " Blue Series of Question Compends;" and the claim is made for the following points of excellence : 1. Professional distinction and reputation of authors. 2. Conciseness, clearness, and soundness of treatment. 3. Size of type and quality of paper and binding. ■*;:r Any of these Compends will be mailed on recei-)'- of price. 21 22 W. B. SAUNDERS' I. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M. D., Pro- fessor of Therapeutics and Materia Medica in the Jefferson Medical Col- lege of Philadelphia; Physician to St. Agnes' Hospital and to the Medical Dispensary of the Children's Hospital; Laureate of the Royal Academy of Medicine in Belgium, of the Medical Society of London, etc. Third edition, revised and enlarged by the addition of a series of handsome plate illustrations taken from the celebrated " Icones Nervorum Capitis'' of Arnold. Crown 8vo, 230 pages, numerous illustrations. Price, Cloth, ^i.oo net; interleaved for notes, $1.25 net. "An exceedingly useful little compend. The author has done his work thoroughly and well. The plates of the cranial nerves from Arnold are superb." — Jourtial of American Medical Association. 2. ESSENTIALS OF SURGERY, containing also Venereal Diseases, Surgical Landmarks, Minor and Operative Surgery, and a Complete De- scription, together with full Illustrations, of the Handkerclyef and Roller Bandages. By Edward Martin, A.M., M.D., Clinical Professor of Genito-Urinary Diseases, Instructor in Operative Surgery, and Lecturer on Minor Surgery, University of Pennsylvania; Surgeon to the Howard Hos- pital; Assistant Surgeon to the University Hospital, etc. Fifth edition. Crown 8vo, 334 pages, profusely illustrated. Considerably enlarged by an Appendix containing full directions and prescriptions for the prepara- tion of the various materials used in Antiseptic Surgery ; also several hundred recipes covering the medical treatment of surgical affections. Price, Cloth, ^i.oo; interleaved for notes, $1.25. "Written to assist the student, it will be of undoubted value to the practitioner, contain- ing as it does the essence of surgical work." — Boston Medical and Surgical Journal. " Cleverly combines all the merits of condensation, while avoiding the errors of super- ficiality and inaccuracy." — University Medical Magazine. 3. ESSENTIALS OF ANATOMY, including the Anatomy of the Viscera. By Charles B. Nancrede, M. D., Professor of Surgery and of Clinical Surgery in -the University of Michigan, Ann Arbor; Cor- responding Member of the Royal Academy of Medicine, Rome, Italy; late Surgeon to the Jefferson Medical College, etc. Fifth edition. Crown 8vo, 380 pages, 180 illustrations. Enlarged l)y an Appendix containing over sixty illustrations of the O.steology of the Human Body. The whole based upon the last (eleventh) edition of Gray's Anatomy. Price, Cloth, ^i.oo; interleaved for notes, $1.25. "Truly such a book as no student can afford to be \N\tho\\i."— American Practitioner and News. "The questions have been wisely selected and the answers accurately and concisely given." — University Medical Magazine. \ CATALOGUE OF MEDICAL WORKS. 23 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC, containing also Questions on Medical Physics, Chen:iical Physiology, Analytical Processes, Urinalysis, and Toxicology. By Law- rence Wolff, M D., Demonstrator of Chemistry, Jefferson Medical Col- lege; Visiting Physician to the German Hospital of Philadelphia; Member of Philadelphia College of Pharmacy, etc. Fourth and revised edition, with an Appendix. Crown 8vo, 212 pages. Price, Cloth, ^i.oo; inter- leaved for notes, $1.25. " The scope of this work is certainly equal to that of the best course of lectures on Med- ical Chemistry." — Pharmaceutical Era. " We could wish that more books like this would be written, in order that medical students might thus early become interested in what is often a difficult and uninteresting branch of medical study." — Medical and Surgical Reporter. 5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M. D., Professor of Gynecology in the Medico-Chirurgical College of Philadelphia; Obstetrician to the Philadelphia Hospital. Third edition, thoroughly revised and enlarged. Crown 8vo, 244 pages, 75 illustrations. Price, Cloth, $1.00 ; interleaved for notes, ^1.25. " An excellent little volume containing correct and practical knowledge. An admirable compend, and the best condensation we have seen." — Souther-n Practitioner. "Of extreme value to students, and an excellent little book to freshen up the memory of the practitioner." — Chicago Medical Times. 6. ESSENTIALS OF PATHOLOGY AND MORBID ANAT- OMY. By C. E. Armand Semple, B. A., M. B., Cantab. L. S. A., M. R. C. P. Lond., Physician to the Northeastern Hospital for Children, Hackney; Professor of Vocal and Aural Physiology and Examiner in Acoustics at Trinity College, London, etc. Crown 8vo, 174 pages, illus- trated. Sixth thousand. Price, Cloth, ^r.oo; interleaved for notes, $1.25. "A valuable little volume — truly a mtdtuni inparvo." — Cincinnati Medical News. "The volume is very comprehensive, covering the entire field of pathologj'." — St. Joseph Medical Herald. 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRESCRIPTION-WRITING. By Henry Morris, M. D., late Demonstrator, Jefferson Medical College ; Fellow of the College of Physicians, Philadelphia; co-editor Biddle's Materia Medica; Visiting Physician to St. Joseph's Hospital, etc. Fourth edition. Crown Svo, 250 pages. Price, Cloth, $1.00; interleaved for notes, $1.25. "One of the best compends in this series. Concise, pithy, and clear, well suited to the purpose for which it is prepared." — Medical and Surgical Reporter. "The subjects are treated in such a unique and attractive manner that they cannot fail to impress the mind and instruct in a lasting manner." — Buffalo Medical and Surgical yournal. 24 ^f^- B. SAUNDERS' 8, 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M. D., author of " Essentials of Materia Medica," etc., with an Appendix on the Clinical and Microscopical Examination of Urine, by Lawrence Wolff, M. D., author of " Essentials of Medical Chemistry," etc. Colored (Vogel) urine scale and numerous fine illustrations. Third edition, enlarged by some three hundred essential formulae, selected from the writings of the most eminent authorities of the medical profession, collected and arranged by WiLLiAM M. Powell, M. D., author of "Essentials of Diseases of Children." Crown 8vo, 460 pages. Price, Cloth, $2.00. " The teaching is sound, the presentation graphic, matter as full as might be desired, and the style attractive." — Atnerican Practitioner and Neivs. "A first-class practice of medicine boiled down, and giving the real essentials in as few words as is consistent with a thorough understanding of the subject." — Medical Brief. " Especially full, and an excellent illustration of what the best of the compends can be made to be." — Gailiard's Medical Journal. 10. ESSENTIALS OF GYNECOLOGY. By Edwin B. Cragin, M. D., Attending Gynaecologist, Roosevelt Hospital, Out-Patients' Depart- ment; Assistant Surgeon, New York Cancer Hospital, etc. Fourth edi- tion, revised. Crown 8vo, 198 pages, 62 fine illustrations. Price, Cloth, ^l.oo; interleaved for notes, $1.25. " This is a most excellent addition to this series of question compends. The style is con- cise, and at the same time the sentences are well rounded. This renders the book far more ea-sy to read than most compends, and adds distinctly to its value." — Medical and Surgical Reporter. " Useful not only to the student who is barely at the threshold of professional life, but to the busy practitioner as well." — New York Medical yournal. II. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, M. D., Clinical Lecturer on Dermatology in the Jefferson Medical College, Philadelphia; Physician to the Skin Service of the Northern Dispensary; Dermatologist to Philadelphia Hospital; Physician to Skin Department of the Howard Hospital ; Clinical Professor of Der- matology in the Woman's Medical College, Philadelphia, etc. Third edi- tion. Crown 8vo, 270 pages, 86 illustrations, many of which are original. Price, Cloth, $l oo; interleaved for notes, ^1.25 net. " An immense amount of literature has been gone over and judiciously condensed by the writer's skill and experience." — New York Medical Record. " The book admirably answers the purpose for which it is written. The experience of the reviewer has taught him that just such a book is needed." — Ne7v York Medical Journal, CATALOGUE OF MEDICAL WORKS. - 2$ 12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. By Edward Martin, A.M., M. D., author of " Essentials of Surgery," elc. Second edition. Crown 8vo, thoroughly revised and enlarged, 78 illustrations. Price, Cloth, $1.00; interleaved for notes, ^1.25. "Characterized by the same literary excellence that has distinguished previous numbers of this series of compends." — American Practitioner and News. "The best condensation of the subjects of which it treats yet placed before the pro- fession."— ^i-^/crt/ News, Philadelphia. " A capital little book. The illustrations are remarkably clear and intelligible." — Aus- tralian Medical Gazette. "We have nothing but praise for the subject-matter of this hod\^."— Bristol Medico-Chi- ru r^ical Journal. 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. By C. E. Armand Semple, M. D., author of " Es- sentials of Pathology and Morbid Anatomy." Crown 8vo, 212 pages, 130 illustrations. Price, Cloth, ^i.oo; interleaved for notes, $1.25. " The leading points, the essentials of this too much neglected portion of medical science, are here summed up systematically and clearly." — Southern Practitioner. " But for the author's judicious condensation of facts, the information it contains would be sufficient to fill an ordinary octavo volume." — College and Clinical Record. 14. ESSENTIALS OF REFRACTION AND DISEASES OF THE EYE. By Edward Jackson, A.M., M. D., Professor of Dis- eases of the Eye in the Philadelphia Polyclinic and College for Graduates in Medicine; Member of the American Ophthalmological Society; Fel- low of the College of Physicians of Philadelphia ; Fellow of the American Academy of Medicine, etc. ; and ESSENTIALS OF DISEASES OF THE NOSE AND THROAT. By E. Baldwin Gleason, S. B., M. D., Clinical Professor of Otology, Medico-Chirurgical College, Phila- delphia; Surgeon in charge of the Nose, Throat, and Ear Department of the Northern Dispensary of Philadelphia ; formerly Assistant in the Nose and Throat Dispensary of the Hospital of the University of Pennsylvania, and Assistant in the Nose and Throat Department of the Union Dispen- saiy, etc. Two volumes in one. Second edition. Crown 8vo, 294 pages, 124 illustrations. Price, Cloth, $1.00; interleaved for notes, $1.25. "A valuable book to the beginner in these branches, to the student, to the busy prac- titioner, and as an adjunct to more thorough reading. 1 he authors are capable men, and as successful teachers, know what a student most needs." — New York Medical Record. " Verj' valuable, since in both sections is given about all that a candidate for examination is required to knowf ." —Medical Times and Hospital Gazette. 26 JV. B. SAUNDERS' 15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, M.D., Attending Physician to the Mercer House for InvaUd Women at Atlantic Ciiy, N.J. ; late Physician to the Clinic for the Dis- eases of Children in the Hospital of the University of Pennsylvania and St. Clement's Hospital ; Instructor in Physical Diagnosis in the Medical Department of the University of Pennsylvania. Crown 8vo, 216 pages. Price, Cloth, $1.00; interleaved for notes, $1.25. " This work is gotten up in the clear and attractive style that characterizes the Saunders Series. It contains in appropriate form the gist of all the best works in the department to which it relates." — American Practitioner and News. " The book contains a series of important questions and answers, which the student will find of great utility in the examination of children." — Annals of Gynecology. 16. ESSENTIALS OF EXAMINATION OF URINE. By Law- rence Wolff, M. D., author of " Essentials of Medical Chemistry/' etc. Colored (Vogel) urine scale and numerous illustrations. Crown 8vo. Price, Cloth, 75 cents. " A little work of decided value." — University Medical Magazine. " A good manual for students, well written, and answers, categorically, many questions beginners are sure to ask." — Ne7v York Medical Record. " The questions have been well chosen, and the answers are clear and brief. The book cannot fail to be useful to students." — Medical atid Surgical Reporter . 17. ESSENTIALS OF DIAGNOSIS. By Solomon Solis-Cohen, M. D., Professor of Clinical Medicine and Applied Therapeutics in the Philadelphia Polyclinic, and Augu.stus A. Eshner, M. D., Instructor in Clinical Medicine, Jefferson Medical College, Philadelphia. Crown 8vo, 382 pages, 55 illustrations, some of which are colored, and a frontispiece. Price, $1.50 net. "A good book for the student, properly written from their standpoint, and confines itself well to its X^-K\."^Neiv York Medical Record. "Concise in the treatment of the subject, terse in expression of fact. . . . The work is reliable, and represents the accepted views of clinicians of to-day." — American Journal of Medical Sciences. "The subjects are explained in a few well-selected words, and the required ground has been thoroughly gone over." — Internatio7ial Medical Magazine. 18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre, M. D., Professor of Pharmacy and Materia Medica in the Uni- versity of Kansas. Second edition, revised and enlarged. Crown 8vo, 200 pages. Price, Cloth, ^i.oo; interleaved for notes, ^1.25. "Covers a great deal of ground in small compass. The matter is well digested and arranged. The research questions are a valuable feature of the book." — Albany Medical Annals. " The best quiz on Pharmacy we have yet examined." — National Drug Register. " The veteran pharmacist can peruse it with pleasure, because it emphasizes his grasp upon knowledge already gleaned." — Western Drug Record. CATALOGUE OF MEDICAL WORKS. 2/ 20. ESSENTIALS OF BACTERIOLOGY: A Concise and Syste- matic Introduction to the Study of Micro-organisms. By M. V, Ball, M. D., Assistant in Microscopy, Niagara University, Buffalo, N. Y. ; late Resident Physician, German Hospital, Philadelphia, etc. Second edi- tion, revised. Crown 8vo, 200 pages, 81 illustrations, some in colors, and 5 plates. Price, Cloth, ^ 1. 00; interleaved for notes, ^1.25. "The amount of material condensed in this little book is so great, and so accurate are the formulse and methods, that it will be found useful as a laboratory Y^^x^AhooV."— Medical Netvs. " Bacteriology is the keynote of future medicine, and every physician who expects success must familiarize himself with a knowledge of germ-life— the agents of disease. This little book, with its beautiful illustrations, will give the students, in brief, the results of years of study and research unaided. 'I— Prtcz/fc Record of Medicine and Surgery. "Thoroughly practical, very concise, clear, well-written, and sufficiently illustrated. . . . The best book of the kind in the English language." — Medical and Surgical Reporter. 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY, their Symptoms and Treatment. By John C. Shaw, M. D., Clinical Professor of Diseases of the Mind and Nervous System, Long Island Col- lege Hospital Medical School; Consulting Neurologist to St. Catherine's Hospital and to the Long Island College Hospital ; formerly Medical Super- intendent King's County Insane Asylum. Second edition. Crown Svo, 186 pages, 48 original illustrations, mostly selected from the Author's private practice. Price, Cloth, |5i.oo; interleaved for notes, ^1.25. "Clearly and intelligently written." — Boston Medical and Surgical Journal. " A valuable addition to this series of compends, and one that cannot fail to be appreciated by all physicians and students." — Medical Brief. " Dr. Shaw's Primer is excellent. The engravings are well executed and very interest- ing.'' — Medical Ti?nes and Register. " Written with great clearness, devoid of verbosity, it encompasses in a brief space a vast amount of valuable information." — Pacific Medical Record. 22. ESSENTIALS OF PHYSICS. By Fred J. Brockway, M. D., Assistant Demonstrator of Anatomy in the College of Physicians and Sur- geons, New York. Second edition. Crown Svo, 320 pages, 155 fine illus- trations. Price, Cloth, ^i.oo net ; interleaved for notes, ^1.25 net. The publisher has again shown himself as fortunate in his editor as he ever has been in the attractive style and make-up of his com-^^-n^s." —American Practitioner and News. "Contains all that one need know of the subject, is well written, and is copiously \\\\i%- trated."— iV^'iJw York Medical Record. "The author has dealt with the subject in a manner that will make the theme not only comparati%'ely easy, but also of \n\.&rts\.."— Medical News, Philadelphia. " Deserving of close investigation at the hands of students and physicians."— ^w^rzVaw Gynecological Journal . 28 jr. B. SAUNDERS' CATALOGUE. 23. ESSENTIALS OF MEDICAL ELECTRICITY. By D. D. Stewart, M. D., Demonstrator of Diseases of the Nervous System and Chief of the Neurological Clinic in the Jefferson Medical College ; Phy- sician to St. Mary's Hospital and to St. Christopher's Hospital for Chil- dren, etc. ; and E. S. Lawrance, M. D., Chief of the Electrical Clinic, and Assistant Demonstrator of Diseases of the Nervous System in the Jefferson Medical College, etc. Crown 8vo, 148 pages, 65 illustrations. Price, Cloth, $1.00; interleaved for notes, $1.25. " Clearly written, and affords a safe guide to the beginner in this subject." — Boston Med- ical and Surgical Journal. " The subject is presented in a lucid and pleasing manner." — Neiv York Medical Record. " A litde work on an important subject, which will prove of great value to medical students and trained nurses who wish to study the scientific as well as the practical points of elec- tricity." — T/ie Hospital, London. " The selection and arrangement of material are done in a skilful manner. It gives, in a condensed form, the principles and science of electricity and their application in the practice of medicine." — Annals of Surgery. " The compilation is a good one, and will be found useful both to students and to men in practice." — New Zealand Medical Journal. 24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, S. B., M. D., Clinical Professor of Otology, Medico-Chirurgical College, Philadelphia; Surgeon in Charge of the Nose, Throat, and Ear Department of the Northern Dispensary of Philadelphia; formerly As- sistant in the Nose and Throat Dispensary of the Hospital of the Univer- sity of Pennsylvania, and Assistant in the Nose and Throat Department of the Union Dispensary. 89 illustrations. Price, Cloth, ^i. 00; inter- leaved for notes, ^1.25. This latest addition to the Saunders Compend Series accurately represents the modern aspect of otological science. The effort has been made to state the Essentials of Otology concisely, without sacrificing accuracy to brevity, and the book, while small in compass, is logically and capably written; it comprises up- ward of 150 pages, with 89 illustrations, most of which are from original sources. DIET LISTS AND SICK-ROOM DIETARY. By Jerome B. Thomas^ M. D. There is here offered, in portable form, as an efficient aid to the better prac- tice of Therapeutics, a collection of Diet Lists and a Sick-room Dietary. It meets a want, for the busy practitioner has but little time to write out Systems of Diet approjjriate to his patients, or to describe the preparati(;n of their food. Com- piled from the mo.st modern works on dietetics, the Dietary offers a variety of easily-digested foods. Send for .sample sheet. Price, ^i.oo. COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at thel expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE [ C28(251 ) lOOM COLUMBIA UNIVERSITY LIBRARIES IteLstx) RD91B381895C A manual ot tnri_moo>r,_^^^_;^ - j,|<,||,|„|,|,||„| 2002110245 RD91 Beck B38 1895 A manu&l of the modern theory and -technique of siirgicai a sepsis. j== m PERSONAL RfifiNERVE SHELF RD31 \03 6' ■w Vi\y ;i V MW o M^