Surgical asepsis, especially adapted to operations in the home of the patient

Front matter

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Preface

The aims of this book are to demonstrate that surgical work may be safely performed in the home of the patient, and to detail the methods which the writer has found best to secure ^such a result.

If the home be a good one,' and if the same degree of surgical skill and nursing can be secured, the home treatment of surgical cases ofTers some very decided advantages over the hospital. The home environments, the greater degree of quiet which may be secured, and the knowledge of the patient that he is among his friends and under the care of his family physician are great aids toward securing that quietude of mind which will hasten the recovery.

After convalescence is established the patient is usually anxious to leave the hospital, and often returns to his home sooner than it is advisable that he should travel. Were he operated on at home he would neither be subjected to this risk nor would the convalescence be retarded by his anxiety to return home.

The methods described in this volume embody the principles conmionly accepted, modified in the manner found most convenient for house-to-house

IV PREFACE.

Operating. It has been written especially for those surgeons who often operate outside of the hospital, and for the general practitioner who may do some surgery or has the after-care of surgical cases.

Only so much of bacteriology and theory have been included as has seemed necessary to the full understanding of the requirements for aseptic work, and to prove the ground taken on some unsettled points.

The author has availed himself of the writers on aseptic technique, and would especially acknowledge the assistance received from the works of Scliimmelbusch, Kelly, and Robb.

Farmington, Maine.

Chapter 1. General Considerations Of Aseptic Wound Treatment

The results which follow the aseptic treatment of wounds have not only made it possible for the general practitioner to undertake surgical work wdiich formerly would have been impracticable for him to do, but they have forced upon him obligations, in sudden emergencies, which he cannot escape.

Moreover, in private surgical practice it is often the family physician who must direct the details of the preparation for the operation, assist in its performance, and carry out the suggestions of the surgeon in the dressing of the wound and the after-care of the patient. He must therefore thoroughly understand the principles and technique of aseptic surgical work, even though he does no operative work. I By an aseptic in contradistinction to an antiseptic technique we mean one in which every article that comes in contact with the wound has been previously freed from active organisms, and one in which no chemical antiseptics are employed in contact with the wound. On the other hand, the antiseptic technique presupposes a certain amount of contamination of the wound, and attempts to destroy, by chemical substances, the bacteria which have gained access to it. \

So long as it was supposed that bacteria gained entrance to the wound principally through the atmosphere, chemical disinfectants in contact with it were deemed necessary. Xow we know that infection nearly always comes from contact, and the exclusion of disease-germs from the wound is more nearly under our control.

^ The use of chemical disinfectants is necessary in the preparation for an aseptic operation, but the antiseptics are used before the Avound is made, and not in contact with it.

The advantage of aseptic wound treatment over the antiseptic is very obA'ious. The more potent antiseptics — as bichloride of mercury, carbolic acid, and iodoform — may produce serious and even dangerous constitutional effects if used on any extensive wound or absorbing surface. In such strength that they are ei^cient as germicides they produce cellular necrosis of the tissues on the surface of the wound. Dr. Halsted has shown that the irrigation of fresh wounds with a solution of bichloride of mercury of only the strength of 1 to 10.000 causes a line of superficial necrosis which can be demonstrated under the microscope. This cellular necrosis retards the repair in the wound and lessens the normal resistance of the tissues to the action of any bacteria which may gain access to them, either during or subsequent to the operation.

Antiseptic solutions should never be used in contact with serous membranes, as they favor the formation of adhesions. In the peritoneal cavity and in joints this is especially disastrous.

Accidental wounds are usually already infected. In such a case the wound may be thoroughly

GENERAL CONSIDERATIONS. 3

washed with some. reHable antiseptic solution and then treated as an aseptic wound.

While the term aseptic would imply that the wound is kept perfectly germ-free, the fact remains that the hands of the surgeon and the skin of the patient cannot be absolutely sterilized by any known method. There are also a small number of bacteria which gain entrance from the air. But the tissues of the body are capable of resisting small numbers of bacteria, so that septic infection and wound suppuration have been almost completely banished from most hospitals and may be avoided in private surgical practice with equal certainty.

There are several factors which determine the existence or non-existence of suppuration in a wound. The principal ones are the number of bacteria present in the wound, the virulence of the organisms, the presence of fluids which may act as culture media for their development, and the resistance of the tissues to the niicrobic invasion.

Watson Cheyne has shown that the number of bacteria introduced not only modifies the symptoms, but also the character, of the septicaemia. He experimented with a pure culture of the proteus vulgaris injected into the muscular tissue of rabbits. He estimated that ^/jq cubic centimeter of a pure culture contained about 225,000,000 bacteria, and he found that this amount caused the speedy death of the rabbit when injected.

A quantity of the same culture representing ^/^^ cubic centimeter caused only a localized abscess at the point of the injection and the death of the animal in six or eight weeks.

Amounts of less than V500 cubic centimeter and containing 450,000 bacteria produced no results.

When the various pus-producing organisms gain access to the tissues they may likewise cause simply an inflammation which does not disorganize the tissues and cause suppuration, or if larger numbers are introduced they may cause a localized suppuration, or they may gain access in such numbers as to cause a rapidly fatal result before suppuration has taken place. The healthy tissues can usually resist a certain number of pathogenic organisms of a given virulence, and it is only in a few instances that a very small number will produce a fatal result.

Different varieties of bacteria vary greatly in the number required to produce a fatal result. One or two of the bacilli of anthrax injected into a rabbit will produce a fatal form of the disease, while it requires at least 1000 of the bacilli of tetanus, and more than 18,000 of the proteus vulgaris to produce the same result.

Not only do the different varieties vary in their virulence, but the same organism may vary greatly, according to its source. The pyogenic organisms from an abscess in active development are much more active than are the same organisms from a chronic suppuration. But the virulence of an attenuated organism may be increased by passing through this active change; so that bacteria taken from a chronic source of suppuration may produce only mild infection, while the bacteria taken from this mild, but acute, case may produce a virulent septicaemia. The colon bacillus is much more virulent when taken from a suppurating peritonitis than when taken from its normal habitat in the intestinal canal.

GENERAL CONSIDERATIONS. 5

Some organisms also seem capable of attacking only certain kinds of tissue. The gonococcus, which is a very virulent organism in the genital tract and the eye, seems almost incapable of existence in any other tissue unless it may possibly be in the joints.

Intraperitoneal injections of pure cultures of the gonococcus into white mice or guinea-pigs cause a localized inflammation and suppuration, which rapidly subsides and the organisms die out. This shows that, while the organisms in large numbers may produce a certain amount of inflammation, they have httle or no power of multiplying or spreading in their tissues. It must be remembered that gonococci are inactive also in the genital tract of all the lower animals ; so that these experiments are of less value than they would otherwise be. But chnical experience has shown that the gonococcus has little pawer of proliferation in the peritoneal cavity of the human subject, and, when this organism alone is found in cases of pyosalpinx, there is little danger of peritonitis.

As has been intimated, a limitation of fluids which may act as culture media lessens the danger of sepsis. For the development of bacteria in a wound it is necessary that there should be both the seed and the soil suitable for its growth.

Serum and blood-clot, when aided by the heat of the body, furnish ideal conditions for the development of bacteria.

Retained fluids in a wound, besides acting as a culture medium, lessen, by their pressure and consequent obstruction of the capillary circulation, the resistance of the adjacent tissues to the action of bacteria. Necrosed tissue from the use of clamps, retractors, strong antiseptics, or the cautery also furnishes a good soil.

It is therefore important that clean incisions should be made, and the tissues should be protected from bruising as much as possible.

Blunt dissection should not be employed except when absolutely necessary. All oozing should be checked and the wound be made clean and dry before it is closed. The same objection which has been made to the use of strong antiseptics may be made to the use of very hot compresses or the hot flushing which is so much used to check capillary oozing. These measures cause coagulation necrosis.

Fluid at a temperature higher than 110° to 112° F. is certainly capable of doing much harm in the peritoneal cavity. After its use it may be observed that the serous membrane has lost its luster and it is much more likely to be invaded by any germs which may be present.

The resistance of the tissues to the action of bacteria is a matter of great importance to us. As was shown by Cheyne in the experiments which have been mentioned, a considerable number of bacteria may be destroyed by the tissue-cells. Prof. J. G. Clark in the Johns Hopkins Bulletin, April, 1897, gives some very painstaking experiments on the tolerance of the peritoneum to a limited quantity of micro-organisms. He also found that the germs are much more readily eliminated by the tissues when they are diluted by sterile fluid which is easily taken up by the lymphatics. This fact, combined with the discovery of Muscatello, that fluids are principally elim-

GENERAL CONSIDERATIONS. 7

inated from the peritoneal cavity through the lymphspaces of the diaphragmatic peritoneum, has led to the postural method of drainage employed by Kelly, of Baltimore, and later by many other surgeons.

This consists in leaving from one to two pints of normal salt solution in the abdominal cavity and the elevation of the foot of the bed eighteen inches. Muscatello found that there is normally a current in the peritoneal cavity which carries fluids and foreign particles toward the diaphragm, regardless of the posture of the animal, although gravity greatly assists or retards this current. In dogs that were suspended with heads down, carmine bodies which had been introduced into the peritoneal cavity appeared in the retrosternal and thoracic lymph-glands in from five to seven minutes, while in animals in which the posture was reversed it was five and one-half hours before they could be recovered in these glands. Wegner also found that the peritoneal cavity of the dog may absorb a remarkable amount of fluid, in some cases amounting to from 3 to 8 per cent, of the bodily weight in one hour.

The tissues dispose of bacteria when encountered in small numbers by the process of phagocytosis. In this process the leucocytes are the most active agents, but the fixed tissue-cells also take a part. The bacterium is enveloped by the cell and is digested by it. Cobbett and Melsome made some interesting observations upon the destruction of bacteria in the peritoneal cavity of rabbits. After injecting 5 cubic centimeters of broth culture which was swimming with streptococci, they killed the animal in thirty hours, and found only one chain of

Streptococci, but many single cocci were found enveloped in leucocytes. In other animals treated in the same manner no active streptococci were found. When a larger number of the bacteria are introduced, the leucocytes are unable to cope with the rapidly multiplying germs, and suppuration or septicemia ensues. Aseptic animal tissue — as catgut or decalcified bone — is removed after the same manner that the bacteria are destroyed.

The general condition of the patient has much to do with the resistance of the tissues to microbic invasion. Especially are the subjects of organic disease of the heart, arterial sclerosis, chronic nephritis, pyelitis, diabetes, and cirrhosis of the liver liable to septic infection. In a recent number of the Johns Hopkins Bulletin Dr. Simon Flexner has called special attention to these causes of septic infection under the title of ''Terminal Infections."

From the results of Dr. Clark's experiments, which have been referred to. Dr. Howard A. Kelly draws the following conclusions : —

1. Under normal conditions the peritoneum can dispose of large numbers of pyogenic organisms without producing peritonitis.

2. The less the absorptive power of the peritoneum, the greater is the danger of infection.

3. Irritant chemical substances injure the tissues of the peritoneum, and prepare a lodging place for organisms which becomes the starting-point for peritonitis.

4. Stagnation of fluids in dead spaces favors the production of peritonitis by furnishing a suitable culture medium for the growth of bacteria.

GENERAL CONSIDERATIONS. 9

5. The association of infectious bacteria with blood-clots in the peritoneal cavity is especially liable to produce peritonitis.

6. Traumatic injury or bruising of tissue are strong etiological factors in the production of sepsis when associated with infectious organisms.

The fact that the tissues are capable of successfully combating a limited number of bacteria should certainly not cause us to relax our vigilance in any way, but it explains why infection does not always follow the entrance of the bacteria which unavoidably gain access to the wound.

Chapter II. Pathogenic Bacteria

Inflammation in all its forms is the result of the action of one or more kinds of pathogenic bacteria upon the tissues.

Suppuration is caused by the presence of some variety of the pus-producing bacteria in such numbers that the tissues are incapable of their destruction and elimination. When present in small numbers these pyogenic bacteria may give rise to a simple non-suppurative inflammation. When the inflammation follows this fortunate course, the bacteria are destroyed by the leucocytes, which pass through the walls of the capillaries and attack the bacteria. Much of the swelling in the affected part is due to this accumulation of leucocytes in the tissues.

When the bacteria are present in such numbers that the leucocytes cannot destroy them, suppuration ensues.

Pus is a mixture of bacteria, leucocytes, and fixed tissue-cells which have been liquefied by the peptonizing action of the bacteria or of ferments produced by them. In rare cases pus, which is free from active micro-organisms, may be found, the bacteria from some cause having died out after suppuration has occurred. In old cases of pyosalpinx it is not unusual to find the pus sterile. (10)

Suppuration always causes both local and systemic disturbance, but either may predominate to such a degree that the other is overshadowed. Locally, it destroys the fixed tissue-cells. The systemic effects may be caused either by the entrance into the circulation of the bacteria themselves or by the toxins which are formed at the point of suppuration.

Septic Intoxication is the poisoning- caused by absorption of the toxins from a localized infection without the entrance of bacteria into the circulation. When this form of infection alone is present, recovery speedily follows the removal of the pus from the local lesion, thus cutting off the supply of the infecting agent.

Bacteraemia is the blood disease caused by the presence and multiplication in the blood of pathogenic bacteria.

Septicaemia is that form of bactersemia in which pyogenic germs invade the circulatory system from some primary seat of infection, and multiply so rapidly in the blood that the patient usually dies within a few days.

Pyaemia is septicaemia plus secondary abscesses, disseminated from an infected thrombus. It is less acute in its course than septicaemia, principally because those cases which we designate septicaemia are so rapidly fatal that there is no opportunity for localized abscesses to form.

There must be some gateway, or atrium, for tlie entrance of the germs to the tissues. The unbroken skin is a very effectual barrier to their entrance, but they may penetrate it through a hair-follicle and give rise to furuncle. Another common entrance is through the gastro-intestinal tract to the general circulation.

Ordinarily, when a small number of bacteria gain entrance to the blood they are destroyed by the tissues without producing symptoms; but any trauma which is sustained may cause a localization of the bacteria at that point by the blood-stasis which the injury causes. It is in this manner, that an inflammation is caused by an injury which does not break the skin.

That pus-microbes are the immediate and essential cause of suppurative inflammation and pus-formation has been well established by clinical observation and experimentation. Whenever the surgeon divides the tissues he makes an atrium for the entrance of pathogenic bacteria. It is not intended, here, to go into the bacteriology of wound infection to any great degree, but it is necessary to note the characteristics of some of the more common pathogenic organisms.

PYOGENIC BACTERIA.

Staphylococcus Pyogenes. — There are three varieties of this organism: the staphylococcus pyogenes aureus, albus, and citreus. These are the most common bacteria which are present, either alone or with other varieties, in acute suppuration. Their frequency is in the order in which they are named. These organisms resemble each other very closely in appearance, with the exception of their color. They are spherical cocci growing irregularly in clusters or in masses. In culture media they grow rapidly at ordinary room temperature, but multiply much more rapidly at the temperature of the body. They have considerable tenacity of life outside the body, and it requires a somewhat higher degree of temperature to destroy them than most other bacteria which are free from spores. They are found almost universally distributed in Nature, being in the soil, on the skin, in water, and, in fact, are usually present on any unsterilized object.

The staphylococcus aureus is the most virulent of these organisms, as well as the most frequently encountered.

Staphylococcus Epidermidis Albns. — Prof. William H. Welch discovered this organism present in the deeper layers of the skin almost constantly, even after the most rigid sterilization. To it he attributes many of the stitch abscesses, although it is very often present in wounds which heal without suppuration. It is the least virulent of all the pyogenic bacteria. In general characteristics it resembles very closely the staphylococcus pyogenes albus, and by many bacteriologists is considered only as a variety of that organism.

Streptococcus Pyogenes. — This is the organism which is usually found in a spreading phlegmonous inflammation. Under the microscope it is seen in chains much like a string of beads. It is not so frequently encountered as are the staphylococci, but it is much more virulent. It causes a rapidly spreading infection, and when present in suppurative peritonitis the peritoneal surface looks blistered and covered with patches resembling wash-leather. When this condition is found the case is always very serious.

SURGICAL ASEPSIS.

Fig. I.

Staphylococcus pyogrones aureus.

Fig. 4.

Bacillus coli communis.

Fig. 2.

Streptococcus pyogenes.

Fig. 3.

o^

Fig. 5.

Bacillus tetani.

Fig. G.

m

Gonococcus.

Bacillus tuberculosis.

Gonococcus of Neisser. — This organism is -the specific cause of gonorrhoea, and has an interest to the surgeon principally from being often encountered in operations complicated with tubal disease.

These bacteria are distinguished by occurring in clusters, within pus-corpuscles. They are very virulent when brought in contact with the mucous surfaces of the genito-urinary tract, but are difficult to cultivate outside the body, and have very little virulence when introduced into the peritoneum or connective tissue.

Its virulence is so slight here that Dr. Kelly has abandoned drainage of the abdominal cavity when the microscope reveals only gonococci in the pus which is encountered.

Bactermm Coli Commune. — This bacillus is always present in the intestinal canal. Usually in conjunction with the staphylococcus or streptococcus pyogenes it is present in appendical and ischio-rectal abscesses. It may also appear in organs remote from the intestinal tract. It is a frequent factor in suppurative inflammation of the gall-bladder. It is this organism which gives the characteristic faecal odor which is commonly observed in appendical abscesses. As the organism is of very slight virulence as compared with the other pus-producing bacteria, this odor is not an unfavorable sign. In shape this bacillus is a rod with rounded ends, sometimes so short as to appear almost spherical and again it may be much longer.

NON=PYOGENIC BACTERIA.

In addition to the bacteria which may produce suppuration in a wound there are many which are capable of producing serious disturbance or a fatal result, even though the wound may heal promptly. These bacteria poison the system principally by the toxins which are formed at the site of the wound and are rapidly taken into the general circulation. Bacteria themselves may also be often demonstrated in the blood and in organs distant from the original entrance of the organisms.

Streptococcus Erysipelatosus. — This organism is the essential cause of erysipelas, which was the bane of the older surgeons. This streptococcus invades the superficial lymphatic channels of the skin exclusively. They appear under the microscope to be identical with the streptococcus pyogenes, and are now regarded as being the same by nearly all bacteriologists. From a clinical standpoint there is abundant proof that erysipelas is caused by its own specific organism, which is so nearly identical with the streptococcus pyogenes in its staining properties, cultural characteristics, and appearance under the microscope that it cannot be differentiated.

Bacillus ' Tetani. — This bacillus is not so commonly encountered as most other forms, but owing to its extreme virulence it is of great interest to the surgeon. It is usually found in the soil and in the excreta of the domestic animals. It is anaerobic, or incapable of multiplying in the presence of oxygen.

The bacilli may retain their vitality, however, for several months in the open air and will take on

PATHOGENIC BACTERIA. IT

active development as soon as favorable conditions are presented. They are most likely to develop in accidental punctured wounds of the hands and feet. Wounds in these situations are most likely to come in contact with soil, and punctured wounds which do not allow the entrance of air are favorable for the development of this bacillus.

The bacilli appear under the microscope as slender rods, and at the temperature of the body they multiply by the formation of spores at one end of the rod, giving it the appearance of a pin or drumstick. This property of spore-formation by the bacillus is of practical importance, as the spores are more resistant to the ordinary means of sterilization than are the bacteria. The spores are not destroyed by a temperature of 165° F. in an hour. They will also resist the action of a solution of bichloride of mercury 1 to 1000 for three hours and a 5-per-cent. solution of carbolic acid for ten hours. To insure their destruction by steam sterilization the fractional method should be used. They are destroyed by boiling water in three to five minutes.

Bacillus of Tuberculosis. — This bacillus is the smallest of the bacteria which are pathogenic to man. It is a slender rod which varies in length, being from one-fourth to three-fourths the diameter of a red blood-corpuscle. Under the microscope it is principally distinguished by its peculiar staining properties.

Tubercle bacilli have considerable power of resistance to external influences, and can retain their vitality outside the body for a long time. Dried

Sputum has been found to contain active bacilli after two months.

From the prevalence of pulmo.nary tuberculosis and the usual carelessness in the disposal of sputa, the germs must be widely distributed.

We would expect that wounds would be more commonly infected by this organism than we find them to be.

The tissues of most healthy persons are resistant to these germs, and Volkmann stated, several years ago, that tubercular infection never follows any extensive trauma, but often does follow slight injuries or contusions. He explained this by assuming that the active tissue changes which accompany any severe traumatism prevents the infection. Since the phagocytic action of the leucocytes has been demonstrated, this action can be easily understood. It is probably by this determination of leucocytes to the seat of injury that cases of tubercular peritonitis are cured by simply opening the abdomen.

The baciUi develop, under certain conditions, by the formation of spores, and these resist the ordinary method of sterilization and require the fractional method. The bacillus of tuberculosis is not a pus-producing organism, and the contents of a tubercular, or cold, abscess is not true pus unless accidentally infected by some of the pyogenic bacteria.

These tubercular abscesses, to prevent secondary infection, should be opened under aseptic precautions.

There are several other pathogenic organisms by which wounds are sometimes infected, but these already mentioned are the more common ones, and the same means which are employed for their destruction will destroy all others.

Many varieties of bacteria, which may be demonstrated under the microscope, are harmless to the human organism.

Chapter III. Sources Of Infection

In the avoidance of infection it is necessary to know every avenue by which bacteria may gain entrance to the wound.

The ways in which they may do this are by the air, the hands of the surgeon or skin of the patient, the surgeon's instruments, by the fluids introduced into the wound, by sponges, by sutures and hgatures, and by the dressings.

This statement presupposes a wound through healthy tissues. The wound may be infected by any of the pathogenic organisms which are already present in the tissues.

Air Infection. — It was formerly supposed that the principal source of wound infection was by air contamination, and it was a2:ainst this source of infection that Listerism was directed. It has been found that the air contains very few micro-organisms, and that these are almost entirely associated with the dry dust floating in it.

The essential conditions for the growth of bacteria — warmth, moisture, and a nutrient medium — are not present in the atmosphere. Only transitorily and in comparatively small numbers do they gain access to it from the warm, moist, and organic material of the earth's surface. Stern has shown that, after the artificial dissemination of bacteria in the air of a (20)

SOURCES OF INFECTION. 21

room, they gravitate to the surface by their weight, and that in half an hour the air is practically germ-free. They can float in the atmosphere only in a dry state, and cannot rise from a moist surface. Any liquid which is loaded with bacteria and even foetid from the products of decomposition cannot give off any bacteria to the air. Only the gaseous products of bacterial action can arise from a moist surface.

Tyndall discovered several years ago (and it has since been confirmed by numerous bacteriologists) that the breath is entirely free from germs. This must be qualified by the statement that particles of mucus or other solid matter which may be carried with the breath may carry bacteria. In a clean room, which is free from dust, air infection may be entirely ignored. It has been estimated that there are more than a thousand times as many germs in a single drop of pus than are ordinarily present in a cubic yard of the atmosphere.

Water Infection. — Almost every wound, whether accidental or made by design of the surgeon, comes in contact with water. If it is accidental, it is "cleansed" by the patient or his friends. When made by the surgeon it is sponged or irrigated. It, therefore, is of. great interest to us to know what organisms water may contain.

Bacteria are always present in water from all sources. Even rain-water is not germ-free, as it collects a certain number, in its descent, from the dust floating in the air.

Water which contains organic material is an ideal culture medium for bacteria, especially if the temperature is favorable. It is the collection of bacteria which causes the greenish collection on the surface of stagnant pools, and the slimy deposit on the sides of vessels in which water has been left standing for some time.

In addition to being a good culture medium, in the course of its percolation through the soil it gathers some of the bacteria which are always abundant in the earth.

Water, in most of our large cities, is taken from some large river which is a receptacle for numberless millions of bacteria from the drainage of other towns on its banks. Even if the original supply is reasonably pure, the water is usually stored in a reservoir, in which all the conditions favorable for the development of bacteria are present.

In country places the supply is most often from a well. This is usually situated in close proximity to the dwelling and also often near the stable. Very few wells in the country are free from contamination by drainage from the soil.