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How to do Aseptic Surgery in Country per cent. of success will not fall far in the rear Practice.

if we will only practice what I am

preaching, Cleanliness in the extreme." Read before the Sixth District Medical Society By this I don't mean that we should only have held at Downs, Kas., October 9, 1890.

our own hands and persons clean, but that our

patient, our assistants, and everything that BY F. M. DAILY, M. D., SCOTTSVILLE, KAS.

comes in contact with our patient should be

religiously and scientifically clean. Suppose GENTLEMEN :—The question of how to we should receive a call to go out in the practice aseptic or clean surgery in the coun- country to-night to do an amputation for a try is one of much importance to the general man whose limb was caught and crushed in practitioner, as on it depends the prevention the greasy cog wheels of some machinery, of much suffering and a safeguard against we find our patient's limb, as well as person, death. In the cities the large and well arrang- an entire stranger to soap and water-how ed hospitals with their corps of assistants shall we proceed to do an aseptic operation, trained and well drilled in the technique of mod- and what materials should we have in our ern antiseptics, it is very easy for the surgeon possession to do it with? Our surgical satchel to perform operations that would seem to the must contain the following: One 5-yard can country physician dangerous to undertake, 10 per cent. iodoform gauze, one 5-yard can especially so if the patient was located in a 5 per cent. carbolized gauze, one-half pound sod house or a Kansas shanty-perhaps miles borated absorbent cotton, one pepper box away from a drug store that carried in stock a filled with Merck's crystals iodoform, a solution pound of absorbent cotton or iodoform gauze. of carbolic acid made in glycerine that one

The country surgeon may be called at any tablespoonful to a pint of water will represent moment to meet formidable injuries, and un- a strength of one per cent., one bottle of Dr. der such unfavorable surroundings that at Bernay's formula of bichloride of mercury first glance it would appear impossible to do tablets-one tablet to a pint of water repreclean surgery. If there are any here to-day sents a strength of 1 to 4.000, one roll of gutlaboring under the impression that aseptic ta percha tissue, and fountain syringe of not surgery cannot be practiced in the country as less than one-half gallon capacity, one bottle well as in the hospitals, I hope they will from filled with sterilized gauze cut in small pieces now on join in the march with progressive for sponges, one-half dozen roller bandages, last surgeons and learn that there is no such thing but not least, one cake of soap with hand and as impossibility and but few failures to record nail brush and a good sharp razor. Now, the by the surgeon who accepts for his guiding cost of the entire outfit will not exceed $7.50, angel, “Cleanliness in the extreme." Upon and can be carried very easily in an ordinarythis one word, “Cleanliness," hangs the key sized valise. Now we will proceed to prepare note to all successful surgery from the lancing our patient for an aseptic operation: Wash, of a gum-boil to an amputation or laparotomy. scrub and shave all about the field of operaWhile we may not handle the scalpel as neat- tion; after shaving, irrigate with a 1 to 2.000 ly and speedily as a Tait or McBurney our bichloride of mercury solution-after these washings the surface is lightly sprinkled with prepared so as to be positively aseptic; the iodoform and a large compress of sterilized following is a very good and sure method of gauze soaked in a 2 per cent. of carbolic acid making them such: Boil silk in water one. solution is bound on the surface covered with half hour and then preserve in 5 per cent. sosome impervious material such as gutta percha lution of carbolic acid. The catgut should be and left on until one is ready to make the in- immersed in 5 per cent. solution of carbolic cisions. By carefully carrying out these pro- acid for forty-eight hours, then in i to 1.000 cesses the surface of the body at the site of bichloride of mercury solution in strong the operative procedure is rendered absolute alcohol for eight days. It is then preserved ly aseptic and the danger from infection of for use in strong alcohol, or equal parts of any wound thoroughly by any microbe from alcohol and oil of juniper; dressings after the the surface is rendered practically impossible. wound is closed are always dry. Dust surface Absolutely the same procedure should be car- with iodoform, place over this several layers ried out by ourselves and assistants in order of iodoform or carbolized gauze, and over this to render the hands and arms aseptic, particu- thick layer of absorbent cotton,over cotton gutlar attention being given to the finger nails. ta percha tissue and roller bandages. Vever put During the operation the hands should be medicine solutions of any kind in an aseptic frequently washed in sterilized water only. If wound, the idea being to add in 110 way to the the operation is an aseptic one, and if not irritation produced by use of knife and other aseptic in a i to 2.000 bichloride of mercury instruments; if the wound is not much irrisolution; the clothing of every one about the 'tated there will not be any greater flour of patient should be prevented from carrying sep-i serum tlian the absorbents are able to carry tic material by wearing a clean shirt or gown away, therefore it is seldom necessary to use a with sleeves rolled well up, as long sleeves are drainage tube. Now, if the wound is already frequent carriers of all kinds of infectious ma- a septic one, how shall we proceed? Carry out terial into wounds. The immediate surround- exactly the same procedure described in an ings of the place of operation should be cov- aseptic operation. The septic or suppurating ered with dry clean towels, over them again surface to be thoroughly irrigated with a i to towels wet in a 2 per cent. solution of carbolic 3.000 bichloride of mercury solution, follow acid. Our instruments must be sterilized by this with that element that excels all others as thoroughly scrubbing with soap and water, a pus searcher and cleanser, namely: per then boil them for twenty or thirty minutes, oxide hydrogen, or in the absence of this any after which they are placed in the platter cov- of the following fluids are good cleansers of ered with a 1 per cent. solution of carbolic septic surfaces: A saturated solution of boric acid and kept there until used, and to which acid, or a teaspoonful of tincture jodine to a they are returned when out of use, after being quart of hot water, or 5 per cent. solution of washed clean. Our instruments should be so carbolic acid. I believe that solutions of constructed that they can be easily taken ! mercuric bichloride should never be used apart so that all joints and irregular surfaces stronger than i to 3.000, and in most cases I may be thoroughly cleansed. The only safe believe thoroughly sterilized hot water to be sponge to use is sterilized gauze, and this is as efficacious as any of the agents mentioned, rendered sterile by boiling in water for two and it has this one advantage--it is perfectly hours—then cut into small pieces and put in harmless to the patient. Such irritants as anstoppered bottles or a glass jar that can be tiseptic fluids should never be used in operamade air tight, keep moistened with 2 per tions about the brain or in abdominal cavity.cent. solution of carbolic acid; after using After the septic surfaces have been treated as gauze for sponging throw in the fire and burn suggested, only in rare cases should the wound so that it will not be brought into use again. be completely closed by sutures-it is usually In abdominal operations sea sponges must be best to pack with iodoform gauze and leave in used as they are more easily accounted for. until loosened by developing granulations: in The ligatures used are either silk or catgut this way the wound can be kept perfectly

aseptic for any length of time providing the Case +--H. Hole, American, farm hand, age external dressings are changed at proper in- 17. On evening of July 4, a horse attached tervals and the same care practiced at each to a buggy got frightened at fire works display, dressing as we carried out during the primary and dashing down the street ran into a crowd operation.

of boys. The point of buggy shaft struck Now, gentlemen, I am sure if you will fol- this young man over upper edge of malar bone low out in every detail the line of practice under right eye, fracturing bone and making mentioned, only adding and improving in the a punctured wound that would admit index matter of cleanliness, you will find all your finger to depth of an inch or more.

The concases go on the road to recovery without much cussion of eye produced a detachment of retipain, no temperature, no pus, and all wounds na resulting in immediate and complete loss made or treated will heal rapidly and kindly. of vision. Irrigated wound with sterilized I will report a few of the cases treated by this water, removing fragments of bone with finmethod in the past six months, and the re- gers, dusted surface with iodoform, packed sults:

with iodoform gauze, dressed with gauze, cotCase 1-1. Farmer, American, age 60. On ton and gutta percha. He was taken to his the evening of March 5, while caring for a home eight miles in the country the same cow she became enraged, goring him in right evening; returned to my office to have wound side below shoulder blade making an ugly examined and redressed on July 6, 9, 12, 15, punctured lacerated wound extending down 18, 21, 25 and 28; discharged patient with to ribs. Treatment--Irrigated wound with wound all filled in with nice healthy tissue sterilized water, dusted surface with iodoform leaving but slight cicatrix and depression. packed with iodoform gauze, over this four This young man never suffered a moment's layers of gauze borated cotton and gutta per- pain, had no swelling, no increase of temperacha tissue and bandage, Examined wound

ture and 110 pus. The injured eye did not March 7, 9, 11 and 17, and discharged even give him the slightest pain or discomfort, patient with wound healed; no pain, no heat, and gave no appearance of any inflammatory swelling or pus.

action. Case 2--J. Carter, farmer, American, age 81, Case 5-H. Tornaby, a farmer, native of suffering with abscess over region of mastoid Norway, age 78, suffering with a hard nodular bone, the result of septic infection from an in- tumor; began to develop around right nipple jury received on scalp two months previous. and had assumed about the size of a goose On March 13 made free incisions down to

egg

Advised removal at once and on Tuesbone, curetted out all necrotic tissue, irrigated day, July 8, assisted by my student and Dr. with 1 to 3.000 bichloride mercury solution, McCasey of Jamestown, in a granary about 6 packed with iodoform gauze with same dress-X12 covered with prairie hay, for an operating ings as described in first case; examined and room, we removed the tumor by elliptical inredressed wound on March 15, 18 and 20; dis- cision keeping clear of indurated tissue about charged patient with wound all filled in with one-half inch, making a wound about five innice, clean, healthy tissue; result, no pain, ches in length and three inches in width; the temperature, swelling or pus.

indurated tissue extended down to ribs. SurCase +-M. Collins, farm hand, American, face sponged dry with gauze sponges, edges age 16, on evening of June 22, while chopping brought together with catgut sutures, passing wood, ax glanced striking foot making a cut one heavy double suture through center or two inches extending to bone; brought sur- base of tumor about 14 inches from edges of faces together with silk sutures after irrigating wound, and tied over a small roll or pledget of thoroughly with sterilized water; dusted with gauze to relieve the tension of small sutures iodoform gauze, dressed with gauze, cotton and assist in counteracting skin and muscular and gutta percha; examined wound on fourth traction ; dusted surface with iodoform and day, removed sutures, found union perfect, applied the dressing described previously; with no pain, no temperature or sweeling. visited patient Friday, July 11, and found him

on

sitting up smoking his pipe; passed a flow of ust, 1890, has proclaimed: '“Avoid the use sterilized water from fountain syringe through of all drugs except strychnine, digitalis, and drainage tube—the exit of water was as clear ammonia,” as the first rule for the treatment as when entering; removed tube and applied of accidents during anæsthesia. Supported dressings with instructions to his son to bring by extended experiments, he brings his weight patient to my office for future dressings. On of evidence in favor of digitalis as being, next tenth day found union complete with not a to strychnine, the most trustworthy drug to moment's pain; no temperature and no pus, counteract the circulatory depression naturand patient only confined to his bed one day. ally produced by the anæsthetic.

Case 6—Isaac McGinnis, farmer, American, Having this late evidence as additional age 50; on July 18, while trying to drive a proof of digitalis being a most reliable heartloaded shell out of gun with a nail the shell tonic, while the correct use of this potent exploded and resulted in tearing the flesh remedy-invaluable, and still standing alone from the palmar surface of three fingers and unsupplanted, in certain cases of lack of leaving the tissues in shreds and pieces; irri- power in the heart—is, as yet, scarcely gengated surfaces thoroughly with sterilized eral; therefore, it was thought appropriate to water, brought fragments together with fine this occasion, to bring under discussion the silk occasionally using a small piece of isin- indications for the use of digitalis. glass plaster on silk prepared with salicylic

By remembering Rosentein's maxim, “dig. acid; dusted surface with iodoform placing italis fills the arteries and empties the veins," over this iodoform gauze spread with ointment the practitioner will rarely experience any 10 per cent. iodoform in vaseline-this was difficulty in deciding when to give, or when put on to prevent gauze from adhering to to withhold the potent digitalis. The great sutures and surfaces of wound. Dressed guiding factor to be remembered about digitwound on July 21, 24, 28, and on August 2, alis is, that it increases the power of ventricdischarged patient, surface all healed with ular contractions, and that the clinical indicausual results, except patient complained of tion for its administration is an empty artery. suffering very much pain on the first night

The therapeutics of cardiac affections has following the injury.

been greatly advanced in recent years, not These are only a few of many minor injur- only by the discovery of numerous hearties and operations that have been treated by tonics, but also by the acquirement of importthis process in the last six months with equal- ant details in regard to the administration of ly as good results in all.

the older remedies, by which their efficiency

has been greatly advanced. Digitalis-Indications for the use of.

Digitalis was long regarded as a cardiac

sedative—“the opium of the heart;" because Read before the Golden Belt District Medical it rendered the heart's action slower, or less Society of Kansas, in Regular Quarterly tumultuous. Slower, certainly, then as now, Session, at Abilene, Kansas, October

in those cases where the rapidity is due to the 2, 1890.

action of an irritable muscle; irritable because

becoming exhausted. But when the rapidity BY WILLIAM B. DEWEES, A. M., M. D., SALINA, of the heart's action is due to nervous disturb

ances, digitalis, then, is not useful, “because it

slows the action of the heart." This is an error, Now that that universally acknowledged for in these cases digitalis exerts no action worth authority, Prof. H. C. Wood, of Philadelphia, estimating, in fact is useless, if not actually in the very able and instructive Address on harmful. Again, in this class of cases, the Anästhesia,* delivered before the Tenth In- heart disturbances are chiefly due to inhibitternational Medical Congress, in Berlin, Aug. ory action of the vagus, and thus the he

* British Medical Journal, Augnt 16, 1890, and Journal | becomes overworked by resistance, at the perAmerican Medical Associution, September 6 and 13, 1890. iphery. Here, then, the indications are arter

KANSAS.

ial dilatation; as in this way the arterioles the left ventricle too swiftly for hypertrophy are dilated, and thus the heart muscle is nour- to be built up to arrest the dilating process, ished by sending more blood to it, which also what is the value of digitalis? Simply inestis a powerful stimulus to the ganglia, thereby imable. It arrests the dilating process; the bringing on the needed systolic action. ventricle recovers its size, and, with that,

It being remembered, that in this class of much of its vigor; the muscle is better nourcases, viz., when heart failure is due to inhib- ished, while that compensatory hypertrophy itory action of the vagus, we find the heart is built up which often enables the afflicted stopping in diastole. The remedy that will one to pursue an active life for years, Cergive the most prompt relief in this class of tainly, on the other hand, both in aortic stencases is nitroglycerine, through its power of osis and aortic regurgitation, while the musreducing peripheral resistance; while digit- cular compensation is complete and sufficient, alis is contra-indicated, because it increases and the patient is fairly well, there is no good heart power as well as the resistance at the end to be attained by giving digitalis. periphery; and it does not increase the nu

We do not give digitalis because there is trition of the heart, but overworks it. In valvular disease present, but when the system other words, digitalis acts as a vis a tergo, is suffering in consequence of the said valvuwhile nitroglycerine acts as a vis a fronte, di- lar lesion. The digitalis has no influence on lates the peripheral vessels and removes the the injured valve, but is of mighty service resistance. In this connection we find Yeo when the muscular hyperplasia, which commakes a most wise remark in his recent pensates the valvular defect to a great extent, “Physiology,” speaking of the special heart is not provided by the powers of nature. By ganglia he says: “These nerve cells only re- the aid of digitalis the natural powers will quire their nutrition kept up by a constant often be enabled to surmount the difficulty blood-supply, in order to develop the energy and secure a muscular growth or hypertrophy, necessary for their functions."

which is practically compensatory. Such "Digitalis is to be given in mitral disease, compensation is most perfectly seen in aortic but withheld in aortic disease,” is a time-honor- stenosis. ed maxim, still impressed with lasting effect In simple dilatation of the left ventricle, withinto the student's mind by some teachers. out necessarily any valvular lesion; the mitral This, as a rule, is misleading. Digitalis is valve may leak, but not as the result of any usually of service in mitral disease—but how distortion of the valve curtains, but rather the about aortic disease? When a hypertrophied ostium has stretched with the yielding of heart left ventricle is struggling against a contracted muscle and the valve curtains become insuffiaortic orifice, but not quite successful--how cient to close the ostium completely on the about digitalis? In those cases the system is contraction of the ventricle. Such a condition suffering from want of arterial blood, because is common where the dilatation has taken the ventricle is unequal to driving a suffici- place too rapidly for the valve curtains to ency of blood through the narrowed ostium in stretch pari passu with the yielding of the the normal time, to keep the arteries full. muscle. Here we find digitalis often acts most potently,

Here digitalis is usually, likewise, of priceindeed furnishes the most brilliant illustra- less value; but its utility will be greatly entions of its properties as a heart-tonic. By in- þanced here, by placing the patient at comcreasing the vigor of the propelling power-plete rest, which means, strictly confined to the ventricular contractions — the normal bed—just as much as if the case were one of amount of blood is pumped into the arteries broken thigh. in the normal time, and thus the arteries Now, when we come to discuss the effects being kept full, tissue nutrition is improved of digitalis upon the right ventricle, there is everywhere, including the structures of the something more to be considered than the heart itself.

heart merely. There is the respiration! There Again, when aortic regurgitation is dilating are about 250 cubic inches of “residual” air

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