PUBLISHED MONTHLY VOL. II. TOPEKA, KANSAS, NOVEMBER, 1890. No. II. How to do Aseptic Surgery in Country per cent. of success will not fall far in the rear Practice. Read before the Sixth District Medical Society held at Downs, Kas., October 9, 1890. BY F. M. DAILY, M. D., SCOTTSVILLE, Kas. if we will only practice what I am now preaching, Cleanliness in the extreme." By this I don't mean that we should only have our own hands and persons clean, but that our patient, our assistants, and everything that 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 machineryof 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 making them such: Boil silk in water onehalf hour and then preserve in 5 per cent. solution of carbolic acid. The catgut should be immersed in 5 per cent. solution of carbolic acid for forty-eight hours, then in 1 to 1.000 bichloride of mercury solution in strong gauze soaked in a 2 per cent. of carbolic acid solution is bound on the surface covered with some impervious material such as gutta percha and left on until one is ready to make the incisions. By carefully carrying out these processes the surface of the body at the site of the operative procedure is rendered absolute-alcohol for eight days. It is then preserved ly aseptic and the danger from infection of any wound thoroughly by any microbe from the surface is rendered practically impossible. Absolutely the same procedure should be carried out by ourselves and assistants in order to render the hands and arms aseptic, particular attention being given to the finger nails. During the operation the hands should be frequently washed in sterilized water only. If the operation is an aseptic one, and if not aseptic in a 1 to 2.000 bichloride of mercury solution; the clothing of every one about the patient should be prevented from carrying septic material by wearing a clean shirt or gown with sleeves rolled well up, as long sleeves are frequent carriers of all kinds of infectious material into wounds. The immediate surroundings of the place of operation should be covered with dry clean towels, over them again towels wet in a 2 per cent. solution of carbolic acid. Our instruments must be sterilized by thoroughly scrubbing with soap and water, then boil them for twenty or thirty minutes, after which they are placed in the platter covered with a 1 per cent. solution of carbolic acid and kept there until used, and to which they are returned when out of use, after being washed clean. Our instruments should be so constructed that they can be easily taken apart so that all joints and irregular surfaces may be thoroughly cleansed. The only safe sponge to use is sterilized gauze, and this is rendered sterile by boiling in water for two hours then cut into small pieces and put in stoppered bottles or a glass jar that can be made air tight, keep moistened with 2 per cent. solution of carbolic acid; after using gauze for sponging throw in the fire and burn so that it will not be brought into use again. In abdominal operations sea sponges must be used as they are more easily accounted for. The ligatures used are either silk or catgut for use in strong alcohol, or equal parts of alcohol and oil of juniper; dressings after the wound is closed are always dry. Dust surface with iodoform, place over this several layers of iodoform or carbolized gauze, and over this thick layer of absorbent cotton,over cotton gutta percha tissue and roller bandages. Never put medicine solutions of any kind in an aseptic wound, the idea being to add in no way to the irritation produced by use of knife and other instruments; if the wound is not much irritated there will not be any greater flow of serum than the absorbents are able to carry away, therefore it is seldom necessary to use a drainage tube. Now, if the wound is already a septic one, how shall we proceed? Carry out exactly the same procedure described in an aseptic operation. The septic or suppurating surface to be thoroughly irrigated with a 1 to 3.000 bichloride of mercury solution, follow this with that element that excels all others as a pus searcher and cleanser, namely: per oxide hydrogen, or in the absence of this any of the following fluids are good cleansers of septic surfaces: A saturated solution of boric acid, or a teaspoonful of tincture iodine to a quart of hot water, or 5 per cent. solution of carbolic acid. I believe that solutions of mercuric bichloride should never be used stronger than 1 to 3.000, and in most cases I believe thoroughly sterilized hot water to be as efficacious as any of the agents mentioned, and it has this one advantage-it is perfectly harmless to the patient. Such irritants as antiseptic fluids should never be used in operations about the brain or in abdominal cavity.After the septic surfaces have been treated as suggested, only in rare cases should the wound be completely closed by sutures-it is usually best to pack with iodoform gauze and leave in until loosened by developing granulations; in this way the wound can be kept perfectly aseptic for any length of time providing thei Case 4-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. The con 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. cases 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 I-M. 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 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 no pus. The injured eye did not on 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. Case 2-J. Carter, farmer, American, age 81, suffering with abscess over region of mastoid bone, the result of septic infection from an injury received on scalp two months previous. On March 13 made free incisions down to bone, curetted out all necrotic tissue, irrigated with 1 to 3.000 bichloride mercury solution, packed with iodoform gauze with same dressings as described in first case; examined and redressed wound on March 15, 18 and 20; discharged patient with wound all filled in with nice, clean, healthy tissue; result, no pain, temperature, swelling or pus. Case 4-M. Collins, farm hand, American, age 16, on evening of June 22, while chopping wood, ax glanced striking foot making a cut two inches extending to bone; brought surfaces together with silk sutures after irrigating thoroughly with sterilized water; dusted with iodoform gauze, dressed with gauze, cotton and gutta percha; examined wound on fourth day, removed sutures, found union perfect, with no pain, no temperature or sweeling. action. Case 5-H. Tornaby, a farmer, native of Norway, age 78, suffering with a hard nodular tumor; began to develop around right nipple and had assumed about the size of a goose egg. Advised removal at once and on Tuesday, July 8, assisted by my student and Dr. McCasey of Jamestown, in a granary about 6 x12 covered with prairie hay, for an operating room, we removed the tumor by elliptical incision keeping clear of indurated tissue about one-half inch, making a wound about five inches in length and three inches in width; the indurated tissue extended down to ribs. Surface sponged dry with gauze sponges, edges brought together with catgut sutures, passi ag one heavy double suture through center or base of tumor about 14 inches from edges of wound, and tied over a small roll or pledget of gauze to relieve the tension of small sutures and assist in counteracting skin and muscular traction; dusted surface with iodoform and applied the dressing described previously; visited patient Friday, July 11, and found him. 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 anesthesia. 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 anesthetic. 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, "digacid; 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 following the injury. These are only a few of many minor injuries and operations that have been treated by this process in the last six months with equally as good results in all. Digitalis-Indications for the Use of. Read before the Golden Belt District Medical The therapeutics of cardiac affections has been greatly advanced in recent years, not only by the discovery of numerous hearttonics, but also by the acquirement of important details in regard to the administration of the older remedies, by which their efficiency has been greatly advanced. Digitalis was long regarded as a cardiacsedative-" the opium of the heart;" because it rendered the heart's action slower, or less tumultuous. Slower, certainly, then as now, in those cases where the rapidity is due to the 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 KANSAS. 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 Anæsthesia, 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 heart * British Medical Journal, August 16, 1890, and Journal becomes overworked by resistance, at the perAmerican Medical Association, September 6 and 13, 1890. iphery. Here, then, the indications are arter 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 mus reducing 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 nuWe 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 compensation is most perfectly seen in aortic stenosis. "Digitalis is to be given in mitral disease, but withheld in aortic disease," is a time-honored 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-hanced 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 being kept full, tissue nutrition is improved everywhere, including the structures of the Now, when we come to discuss the effects of digitalis upon the right ventricle, there is something more to be considered than the heart merely. There is the respiration! There Again, when aortic regurgitation is dilating are about 250 cubic inches of “residual” air heart itself. |