The rules of aseptic and antiseptic surgery; a practical treatise for the use of students and the general practitioner

Front matter

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Preface

The object of this volume is a systematic yet practical presentation of the Listerian principle that has revolutionized surgery within the last fifteen years. Its adoption has wrought so many incisive changes in practice, has shifted the surgeon's standpoint regarding all the important disciplines of the art in such a radical manner, that most English text-books of surgery, even those recently published, have become partly or entirely inadequate to the wants of the modern physician.

To a large number of medical men the aseptic and antiseptic methods present an incongruous chaos of seemingly contradictory and often incomprehensible detail, arbitrary and varying, according to the predilections or whims of this or that teacher.

Yet the principle involved is based on the correct observation of a common biological process — namely, that of the decomposition of organic substances. The well-known methods employed since the earliest dawn of civilization for the preservation of organic, especially animal, substances, are based upon the empirical yet correct appreciation of the causes of putrefaction, and the practical adaptation of these methods to the healing of operative or accidental wounds contains the whole essence of the new surgery.

Evils that former generations of surgeons deplored, but could not effectually combat, such as septicaemia, pysemia, hospital gangrene, and erysipelas, have been much abated, as a direct consequence of a clear understanding of their essential nature and causation.

Prevention has become the watchword of modern practice, and it can be said that, by the successful employment of the preventive methods of the present day, surgery has become a conservative branch of the healing art.

iv PREFACE.

The elimination of the accidental disturbances of repair caused by wound infection has depressed the percentage of mortality following amputation of the extremities from an average of thirty-five per cent to about fifteen per cent.

The dread of undertaking and submitting to a surgical operation has greatly diminished, and timely — that is, early — surgical interference has become more and more frequent, to the great advantage of both patient and physician.

As a direct consequence of the implied obligation of rendering timely aid where possible, a laudable eagerness for an early diagnosis is developed, and, there being so much to be gained by diagnostic knowledge, thorough and practical study of the morbid processes requiring surgical aid has been greatly stimulated.

The fear of suppuration with its dreadful consequences does not stay now the hand of the surgeon as of old, when an operation was always considered a forlorn hope and a last resort. Strangulated hernise, for instance, are not allowed to gangrene as often as formerly, and herniotomy is readily resorted to, as it is well known that the dangers of an aseptic herniotomy done on a healthy gut are diminutive in comparison to the certain and enormous danger of strangulation itself.

By the conviction that a fault of omission may be followed by irremediable mischief, the sense of responsibility is stirred up to vigilance, which again breeds self-reliance and firmness of purpose in advising and carrying out incisive measures, made clearly necessary by a well-recognized danger to life or limb. And an additional degree of responsibility is imposed by the very safety of aseptic operations.

It can not now be successfully denied that the surgeon's acts determine the fate of a fresh wound, and that its infection and suppuration are due to his technical fmdts of omission or commission.

The principle underlying antiseptic surgery has ceased to be the subject of serious controversy. The author does not undertake to prove each of his statements to the satisfaction of those who look but see not. His object is instruction rather than controversy. Every one will have to pass his period of apprenticeship with its blunders and lessons. But he who becomes a master, to whom the primary healing of a fresh wound remains not a curiosity but becomes a matter of course, will not doubt the great change that has come over surgery.

PREFACE. v

The purely practical tendency of the work made a rather free arrangement of the several parts of the subject-matter a necessity, or at least a convenience ; yet a sufficiency of systematic order was preserved to give the collection of papers the character of a well-rounded, organic whole.

The author begs to state explicitly that completeness — that is, the inclusion of all the disciplines of surgery — was not aimed at, else a complete text-book of surgery would have resulted. The leading idea, traceable through all the matter contained in the book, is to illustrate the incisive practical changes that the adoption of aseptic and antiseptic methods has wrought in surgical therapy. Hereby the changes in wound treatment are meant, as well as the notable extension of active surgery into fields formerly considered a noli me tang ere.

As a consequence of the stupendous growth of operative surgery within the last decade, a fruitful development of operative technique is to be noted also. In accordance with the desire of the author to present to the profession a vivid and true picture of contemporaneous methods, the terms used as the title of this work should be accepted in their widest significance.

Confinement to the meager details of those manipulations which, strictly speaking, constitute aseptic and antiseptic measures, would have yielded an inadequate and tedious compilation. On the other hand, it is hoped that the pathological and technical diversions, introduced for the sake of laying a rational foundation to the principles composing the essence of antiparasitic surgery, may be admitted as germane to the subject.

The methods of wound treatment herein explained are to a certain extent still undergoing changes, hence should not be accepted as final. Yet it is undeniable that, as the clearness of the comprehension of the simple principle of asepticism applied to wound treatment has advanced, so the frequent changes and bewildering vacillation characteristic of the experimental stage of the new discipline have naturally given way to steadier methods. At present, changes are not so frequent as formerly, yet progress, especially the conquest of new fields for the legitimate practice of active surgery, is not at a standstill.

The author is well aware that the practical directions recommended by him are not the only ones that lead to success. Yet, in the main, he vi PREFACE.

lias refrained from quoting other authorities. As reasons for this may be adduced, first, the disinclination to write a bulky text-book, and, further, the knowledge that the interest of the reader is proportionate to the directness and immediate character of the facts and thoughts contained in the work under perusal.

As far as possible, all important statements will be found borne out by illustrative examples taken from the author's personal experience.

The author is much indebted to the gentlemen composing the house staffs of the German and Mount Sinai Hospitals for the ready kindness and courtesy with which their help was proffered in tracing and extracting histories of cases, and in making the very numerous photographic plates that form the bulk of the illustrations.

Great technical difficulties, inherent to the unfavorable season, the small space and inadequate lighting of the operating-rooms of the mentioned hospitals, had to be overcome in exposing the sensitive plates. The matter was rendered still more difficult by the circumstance that operating and photographing were done by one and the same set of persons, and that the welfare and interests of the patients themselves had constantly to be sedulously considered.

In view of the defective character of many of the author's negatives, the greatest praise belongs to Mr. William Kurtz, to whose artistic taste, skill, and versatility is due their excellent reproduction by phototypographic process.

Proper credit is given for the lithographic plates copied from Rosenbach, for the excellent microphotographs reproduced from Koch's classical reports, and for a few other illustrations borrowed from Esmarch, Henke, and Bumm.

In conclusion, the author may be permitted to express the hope that, by publishing his share of experience gathered from a modest public and private practice, he may succeed to somewhat propagate and popularize the principles and practice of antiparasitic surgery.

New York, September 3, 1887.

Contents

p AET I. —ASEPSIS.

CHAPTER I. What are Sepsis and Asepsis ?

PAGE 3

Chapter II

Aseptic Wounds — Aseptic Treatment I. General remarks II. Rules of surgical cleanliness

1. Hands

2. The instruments .

3. Wound irrigation

4. Sponges

5. Materials for ligatures and sutures

6. Drainage-tubes and elastic ligatures

7. Disinfecting lotions

8. Dressings .

(1) Types of dressings

a. Simple exsiccation. Bismuth, iodoform

b. Chemical sterilization combined with exsiccation.

c. Schede's modification of the dry dress

"the moist blood-clot

d. Simple chemical sterilization. Moist dressings

(2) Preparation of dressings

a. Gauze ....

(a) Corrosive-sublimate gauze

(b) Iodoformized gauze

b. Absorbent cotton, or common cotton batting

c. Sawdust

d. Moss .

III. Practical application of rules

1. In operating

2. Change of dressings .

IV. Aseptic measures in emergencies

Operating bag and kit

Dry dressings favoring the organization of

10 11

11 11 12

13 14

Chapter III

Soiled Wounds. — Antiseptic Treatment. — Difference between Aseptic and Antiseptic Methods. — Illustration of Antiseptic Method ........ 27 viii CONTENTS.

Chapter IV. Page

Special Rules regarding the Treatment of Accidental Wounds .... 29

I. Temporary measures .29

II. Definitive relief 31

1. Contaminated wounds . 31

2. Aseptic wounds .33

3. Gunshot wounds 34

Chapter V

Special Application op the Aseptic Method . . . ... . . 35

A. General principles . . . .35

I. Technique of surgical dissection 35

II. Sutures 43

III. Drainage .45

h. Application of aseptic method to diverse organs and regions . .... 47

I. Ligatures of arteries in their continuity 47

II. Extirpation of tumors 50

Preservation of asepsis .......... 50

Complete removal , .50

III. Amputation of limbs . . .59

1. Aseptics and antiseptics of amputation ....... 59

a. Clean cases 61

b. Mildly septic cases 63

c. Septic cases of greater intensity 64

2. Haemorrhage 66

a. Artificial anaemia 66

b. Ligatures and final haemostasis 69

3. Securing of a good stump . , -. . .71

IV. Operations about non-suppurating joints 73

1. Puncture and irrigation . . . . . . . . .73

2. Arthrotomy 75

a. Hydrops genu . . 75

b. Vegetations 76

c. Floating bodies of the knee-joint . . 77

d. Suturing of the fractured patella 77

3. Arthrotomy for irreducible or habitual dislocation, and for deformity due to

fracture . 79

V. Operations for deformities . 83

1. Knock-knee and bow-leg 83

2. Bony anchylosis in a vicious position 84

3. Deformed callus ^ . . . .85

4. Club-foot and pes valgus 85

VI. Plastic operations . . . 88

VII. Aseptics of the oral cavity 93

VIII. Laryngeal operations 97

1. Tracheotomy . . . 97

a. Superior tracheotomy 99

b. Inferior tracheotomy ........... 100

2. Laryngofissure „.„..... 103

3. Extirpation of the larynx ..,„»„, ... 104

CONTENTS.

IX

PAGE

IX. Goitre . .107

X. Amputation of the breast 109

XL Abdominal operations 115

1. General remarks 115

2. Herniotomy 117

a. Herniotomy for strangulation 119

b. Radical operation for hernia 128

3. Laparotomy 133

a. Exploratory incision 133

b. Abdominal tumors 133

(a) General remarks ' 133

(b) Special observations .......... 140

(a) Ovarian tumors . . . . 140

()3) Supra-vaginal hysterectomy 143

(y) Nephrectomy 145

c. Gastrostomy ' . . . . . . . 146

d. Colotomy 147

(a) Lumbar colotomy . . . , 147

(6) Inguinal colotomy 148

XII. Hydrocele, varicocele, and castration . . 149

1. Hydrops of the tunica vaginalis . 149

2. Varicocele 151

3. Castration - . . . . 152

XIII. Aseptic operations on the rectum 154

1. General observations 154

2. Hemorrhoids 154

3. Rectal tumors 157

XIV. Aseptics of the bladder 159

1. Catheterism 159

2 Litholapaxy 161

3. Cystotomy 162

a. Perineal section 162

6. Suprapubic section 163

Chapter VI

Natural History of Idiopathic Suppuration. — Treatment of Suppuration I. The cause of suppuration, or phlegmon II. Portals of infection

1. Infection through lesions of the skin .

2. Infection through lesions of the mucous membranes

III. Entrance, progress, and localization of the infection .

Mechanical irritation . . . ...

Chemical and caloric irritation ....

IV. Development of phlegmon

V. Spread of suppuration

VI. Diagnosis and treatment of phlegmon

PAGE

1. General principles . ." . 184

a. Superficial suppuration, or septic ulcer 185

b. Cutaneous and subcutaneous phlegmon 185

c. Deep-seated or subfascial phlegmon. Lymph-gland abscess . . .189

d. Acute infectious osteomyelitis . . .191

e. Chronic suppuration due to bone necrosis. Necrotomy . . . .194

2. Phlegmonous affections of some special regions 208

a. Face. Floor of the mouth. Neck. Temporal and mastoid regions . 208

(a) Face 209

(a) Fauces and pharynx 211

()3) Submaxillary and parotid cynanche 217

(7) Acute glandular abscesses of the anterior and lateral cervical regions 220

(8) Glandular abscesses of the temporal, mastoid, and occipital regions 221

b. Mammary and retro-mammary abscess 223

c. Empyema 226

d. Phlegmon of the palmar aspect of the hand, of the arm, and axilla . . 230

e. Suppurative affections of the lower extremity 239

(a) Ingrown toe-nail 239

(b) Chronic ulcers of the leg 241

(c) Acute suppuration of the prepatellary bursa 242

(d) Acute suppuration of the knee-joint . • . . 242

(e) Suppuration of the inguinal glands 245

/. Perityphlic abscesses . . . . . . . . 246

g. Abscess of the liver . 251

h. Lumbar abscesses . . . 251

i. Anal abscess. Fistula in ano 254

CHAPTER VIII. Natural History and Treatment op Tuberculosis 263

I. Etiology of tuberculosis. Tubercle bacillus . 263

II. Complication of tuberculosis with pyogenic or suppurative infection . . . 26*7

III. Treatment of tuberculosis 267

General principles 267

Local treatment of tuberculosis . 268

1. Cutaneous tuberculosis. Lupus 268

2. Tuberculosis of the mucous membranes 269

3. Tuberculosis of the lymphatic glands, or scrofula 269

4. Tuberculosis of tendinous sheaths . - 271

5. Tuberculosis of bone. Caries. Cold abscess ...... 273

6. Tuberculosis of joints. White swelling ...... 275

CONTENTS. xi

PAGE

General part . . . 275

a. Technique of joint exsection ........ 275

(a) Septic injection from without 275

(b) Complete removal of tuberculous tissues 276

(c) Control of haemorrhage . ... . . . 276

(d) Preservation of function 276

b. After-treatment . . . - . .277

Special part 278

a. Shoulder- joint 278 d. Hip-joint 285

e. Knee-joint 287

/. Ankle and foot .-.„.. 293

Pakt IV.— GONOKKHCEA :

ITS ANTISEPTIC TREATMENT.

CHAPTER IX. Natural History and Treatment of Gonorrhcea 299

I. Etiology of gonorrhoea. Gonococcus . . 299

II. Treatment of gonorrhcea 301

1. Acute gonorrhcea. Clap 301

a. Anterior gonorrheal urethritis 302

b. Deep-seated gonorrheal urethritis 304

2. Chronic gonorrhoea. Gleet 307

a. Inflammatory stenosis (incipient stricture) and permanent or cicatricial

stricture of the urethra 307

(a) Anterior urethra 307

(6) Deep urethral strictures 313

b. Vegetations of the urethra 315

c. Granular urethritis . 815

d. Chronic catarrh of the posterior part of the urethra, and chronic cystitis . 315 p ART V.— SYPHILIS :

ASEPTIC AND ANTISEPTIC TREATMENT OF ITS EXTERNAL LESIONS.

CHAPTEE X.

Aseptics and Antiseptics applied to External Syphilitic Lesions .... 321

1. Aseptic treatment of primary induration 321

2. Antiseptic treatment of the primary syphilitic ulcer . . . . . 324 a. Chemical sterilization and surface-drainage by medicated moist dressings 324

6. Chemical sterilization by strong caustics 325

c. Sterilization by the actual cautery . . . . . . . . 326

Chapter I. What Are Sepsis And Asepsis?

It is not intended here to enter into an exhaustive exposition of the essence of suppuration and the whole complex of conditions known under the name of sepsis. It may suffice for the present to give a rough outline of the views that prevail regarding the causation of the conditions in question.

Albuminoid substances, such, for instance, as blood or blood-serum — in fact, all the tissues of the dead animal body — will become putrid under certain well-known conditions. These are, first, moisture ; secondly, a certain temperature called warmth, for short; and, thirdly, the presence of living organisms, or fungi, named schizomycetes, better known under the name of bacteria and micrococci. If all these conditions are present, the animal substance in question will ferment or putrefy. Absence of any one of these conditions will be sufficient to prevent decomposition. To illustrate this proposition, we shall mention common facts. Fresh meat or fish, well dried, can be indefinitely preserved ; freezing and, to a certain extent, roasting will also prevent its spoiling ; and, lastly, exclusion of micro-organisms by air-tight packing or sealing, after boiling, will insure preservation for an indefinite length of time.

The active agents of decomposition are the micro-organisms, which will develop at once their disintegrating activity as the conditions favorable to their develojmient (moisture and a certain temperature) are present.

We then either thoroughly dry the substance to be preserved or produce and preserve a very low or very high temperature in it, all of which will prevent the development of fungi. Exclusion of the fungi is herein unnecessary. The third mode of preservation is that employed in canning meats. They are first boiled thoroughly, then the vessel wherein this boiling was done is hermetically sealed while the substance is still very hot. Here we have a combination of first destroying the vitality of such fungi as are contained in the meat before boiling, and, secondly, exclusion of access of new micro-organisms to the sterilized substance.

Note. — The most effective sterilizer is the actual cautery. It not only destroys all the noxious germs contained within the tissues, but at the same time provides these with an often dry and always hermetic seal against further infection. If the eschar and its vicinity be well dusted

4 EULES OF ASEPTIC AND ANTISEPTIC SUEGEEY.

with iodoform-powder, it will often happen that complete cicatrization will take place beneath its protection, even before the detachment of the eschar.

An accidental or surgical wound presents conditions that are eminently favorable for the development of the fungi in question. The oozing blood and lymph, the bruised and dead cells of the various exposed tissues, furnish, severed from their natural connections, the moist pabulum of a proper temperature. The myriads of particles of filth or dust, filling the air in all inhabited localities, contain, according to indubitable evidence, a very large proportion of spores or seeds that, on falling upon the wound and its secretions, promptly develop into fungi, and at once set up a fermentative process known as decomposition.

The products of this fermentation are more or less highly poisonous substances — Bergmann's sepsin, or the ptomaines of the French authors. They promptly set up local changes in the shape of inflammation, and cause systemic trouble — that is, septic fever.

It is further necessary for us to know that in septic processes of a wound not only the ptomaines are absorbed by the lymphatics, but that often an actual invasion of the living tissues by the fungi will take place, and that the lymphatics and veins will also serve as channels for the importation of dangerous quantities of fungi into the circulation. Secondary deposits, metastases, will then easily occur.

Clinical observers properly distinguish between different, more or less intense forms of septic infection, in which bacteriology, however, does not always demonstrate correspondingly different forms of fungi. On the other hand, it is known that impoverished nutrition, but especially a certain morbid state, namely, diabetes mellitus, presents an extremely favorable condition for the development of bacterial sepsis.

Regarding syphilis and tuberculosis, this can not be said, as it is not difficult in these conditions to prevent suppuration of accidental or surgical wounds.

Case. — In 1879 the author removed from the lumbar region of a young brewer a good-sized lipoma. His skin was covered at the time with a recent syphilitic roseola following a chancre. Under ordinary antiseptic precautions prompt union by the first intention followed, although the treatment was altogether ambulatory, the patient having been operated on and treated throughout at the German Dispensary.

Prompt primary healing of the wounds caused by the extirpation of syphilitic buboes is a rather common experience in the syphilitic ward of the German Hospital.

The excellent results obtained after exsections of tuberculous joints are also proof positive of the assertion that tuberculosis in itself does not dispose to suppuration and sepsis, and that prevention of septic processes in the wounds of the victims of tuberculosis is not difficult.

Diabetes mellitus, however, does undoubtedly heighten the disposition to septic conditions. Ordinary antiseptic precautions often fail to prevent suppuration ; hence, an injury, or the necessity of a bloody operation in a diabetic, should never be treated lightly.

It is the immortal achievement of Lister to have first attributed to fer-

AKKPTIO WOUNDS ASEPTIC TREATMENT. 5

mcntativc influences fche disturbances of repair, and to have led woundfcreatment into a rational, hence successful, direction.

Modern wound-treatment is based entirely on the old and well-known principles of the preservation of organic substances. Of the several modes of preservation, freezing is the only one that is inapplicable in human surgery. Exsiccation, however, and burning with the actual cautery (rousting) ; then chemical sterilization by germicides, and the combination of chemical sterilization with exsiccation, contain the essence of aseptic surgery. They insure wounds against decomposition, and are a secure preventive of suppuration.

Chapter II. Aseptic Wounds— Aseptic Treatment

I. GENERAL REMARKS.

Supposing that the skin in the region to be operated on be shaved, then energetically scrubbed in hot water with soap and a clean brush for five ininutes, then the surgeon's hands be scrubbed, likewise his knife, and now an incision be made through the skin ; supposing that this happen in an atmosphere free from particles of dry filth called dust : such a wound could be safely termed a clean or aseptic one. All particles of filth adhering to skin, hands, and instrument were removed by this simple process of scrubbing, and no new particles could settle down out of the atmosphere, which we assumed to be free from dust.

Experience has taught that such a wound, however large, will heal without suppuration, first, if its edges be approximated by sutures made with a clean needle; and (dean wire, silk, or gut; and, secondly, if the immunity from an invasion of filth be maintained until the bloody scrum marking flu; line of union become dry.

But we can vary our experiment, and show that a wound can heal without suppuration even if contact of the walls of the same be imperfect or none.

(Use. — Mrs. J. R., aged forty-nine; branchial cyst of the submaxillary region of the size, of an orange. Had been punctured a number of times. Oct. 7, 1882. — Incision of six inches in length ; difficult extirpation. The large vessels of the neck were freely exposed, a considerable affluent of the deep jugular vein was deligated. Catgut used was rather brittle. Suture and drainage of the large wound. Antiseptic dressings. Immediately after the operation patient had a severe coughing spell. Oct. 12. — On changing the dressings it was found that the interior of the wound was distended by a massive blood-clot, giving an appearance as though the tumor had not been removed at all. 8

6 KULES OF ASEPTIC AND ANTISEPTIC SURGEKY.

Sanguinolent serum was discharging from the drainage-tube. Dressings renewed. Oct. 16. — Tumor much diminished in size. Drainage-tube removed. Oct. 20. — Wound firmly healed; outline of neck normal. Throughout, normal temperatures.

Here we see that undoubtedly secondary venous haemorrhage had taken place into the large cavity of the wound. The distention did not reach a sufficient degree to produce a rupture of the line of sutures. The enormous clot was rapidly absorbed, and the wound healed without suppuration, though not by primary adhesion. If the wound had not been aseptic, putrefaction of the clot and dangerous septic processes would have inevitably followed.

Still more curious is the course of an aseptic wound that is not united at all, but is left gaping, provided that suitable means are employed to preserve its aseptic character.

Case. — Mrs. 0. T.. aged forty-three, came from Ohio to have a syphilitic defect of the nose repaired. Total rhinoplasty, Sept. 18, 1883, at Mount Sinai Hospital. A suitable flap containing the periosteum was raised from the forehead. The edges of the frontal wound could not be drawn together, therefore a properly shaped, well-disinfected piece of rubber tissue was laid on it, and this was covered with an iodoform dressing. Sept. 23. — Stitches removed from nasal sutures. Dressing on forehead dry, therefore it was left undisturbed. Oct. 1. — Dressing of frontal wound being removed, the rubber-tissue covering became visible ; after this was taken away the edges of the wound were found to be cicatrized to the width of half an inch on both sides. A moist, fresh-looking remnant of the blood-clot was still covering a strip of the middle of the wound. No suppuration whatever. Dressings renewed. Oct. 6. — Entire wound cicatrized with the exception of a spot as large as a penny at the upper end. Oct. 10. — Discharged cured.

Here, then, is an example of the now commonly observed fact that a gaping defect will cicatrize over without suppuration if putrefactive changes be excluded from the clot filling up the gap. This observation involves a radical difference from the old tenet that whatever wound does not heal by primary adhesion must heal by suppuration. A third possibility ha& become demonstrable, for which older pathology had no exjdanation.

It is necessary to state that in both of the latter examples the condition of a dustless atmosphere during the time of the operation was not present j the operations were done in ordinary rooms, openly communicating with the dusty streets of New York, yet the behavior of the wounds was perfectly correct.

The extreme difficulty of preparing and maintaining a dustless atmosphere in a room of an inhabited locality is well known to everybody, and, as a matter of fact, the general practitioner must and will have to do his surgery in more or less dusty rooms. Since the procurement of this condition is practically unattainable, frequent irrigation or rinsing of the wound becomes a necessity. But even a constant and powerful stream of fluids will not be able to dislodge all the particles of dust that may have settled down upon and insinuated themselves into the nooks and crevices of a wound. Hence it is desirable to employ a liquid that, aside from its non-irritant quality, will have the property of neutralizing or rather extinguishing the noxious effects of those particles of dust that can not be washed away by the irrigation, but remain imbedded in the tissues. This is chemical sterilization.

Different disinfecting solutions are used for this purpose to answer various requirements. Their composition and uses will be mentioned hereafter.

Note. — Kiimmel, of Hamburg, has shown that a dustless operating-room can be had in a well-appointed hospital, and Neuber, of Kiel, has excellent results from operations done in such a dustless room, with well-cleansed hands, apparatus, and instruments, without, the employment of antiseptic fluids. Even the dressings used are not impregnated with any antiseptic chemical, but are merely "sterilized" by being exposed to dry heat. No sponges are used, all blood being removed with a sterilized solution of common salt (6 : 1000), which is absolutely unirritating, and certainly forms the most gentle manner of cleansing a wound.

II. RULES OF SURGICAL CLEANLINESS.

1. Hands. — The hands and forearms, especially the finger-nails, of the surgeon and his assistants should be well scrubbed in hot water with soap and brush for five minutes ; likewise the region of the body of the patient to be operated on after carefully shaving off the hair. After this follows an immersion of the hands in corrosive sublimate lotion for one minute.

Note 1. — Kiimmel's recommendation of green soap (potash or soft soap) is excellent, on account of its great solvent properties.

Note 2. — Rings, especially those having stone settings, should never be worn by the surgeon or his aids in an operation. Bangles, and bracelets of female nurses should not be tolerated. Every one's arms should be bared and scrubbed to the elbows.

2. The instruments should be subjected to a careful and minute cleansing with soap and brush, especial care being taken to remove dry particles of blood, pus, etc., from the grooves and behind the clasps of the more composite instruments, which ought to be taken ajoart each time for cleansing. They should be immersed for ten minutes in a three-per-cent solution of carbolic acid before use.

Note. — The surgeon should learn to get along with as few instruments as possible. In selecting instruments, preference should be given to the most simple. The best instruments are those having smooth and well-polished surfaces ; grooved or roughened handles are hard to clean and unnecessary.

3. Wound Irrigation. — During the operation the wound should be frequently irrigated with the proper kind of a disinfecting fluid ; the hands of the surgeon and his assistants should be also washed at not too long intervals in a disinfecting fluid (corrosive sublimate, 1 : 1000) ; the instruments should be kept immersed in a three-per-cent solution of carbolic acid (which is the least injurious to them).

Note. — Whenever any one of those engaged at an operation touches a not disinfected object — hands a chair, opens the window or door, helps the ansesthetizer during a vomiting spell of the patient, scratches his face, or wipes his nose — it is absolutely necessary that his hands be scrubbed and disinfected anew. Instruments that are accidentally dropped should be left un touched. Raw assistants, and especially nurses, male and female, trained or untrained, should be earnestly instructed beforehand, and constantly watched afterward, regarding this all-important discipline.