PRACTICAL IDEAS ON ANTISEPTIC AND ASEPTICMETHODS IN THE TREATMENT OF WOUNDS.

WITH A REPORT OE FORTY-SEVEN CON-SECUTIVE OPERATIONS FOR NON-SUP-

PURATIVE CONDITIONS, IN THEAUGUSTANA HOSPITAL DURING

THE PAST YEAR.

BY

Dr. A. J. OCHSNER, 8.5., F.R.M.S.SURGEON-IN-CHIEF OF AUGUSTANA HOSPITAL; CONSULTING SURGEON OF HOSPITAL FOR WOMEN AND

CHILDREN, CHICAGO, ETC.

Read before the Chicago Medical Society, May 16th, 1892.

Reprinted from The Chicago Medical Recorder, June, 1892.

press ofIR. IR. tfDcCabe

PRACTICAL IDEAS ON ANTISEPTIC AND ASEPTICMETHODS IN THE TREATMENT OF WOUNDS.

With a Report of Forty-seven Consecutive Operations for Non-Suppurative Conditions, in the Augustana Hospital

During the Past Year.De. A. J. OCHSNER, 8.5., F.R.M.S.

SURGEON-IN-CHIEF OF AUGUSTANA HOSPITAL; CONSULTING SURGEON OF HOSPITAL FOR WOMEN ANDCHILDREN, CHICAGO, ETC.

Antiseptic and aseptic surgery have been discussed so frequentlyand by so many men who are great in their profession, that I cannotventure to speak upon these subjects before this Society without givingthe reasons which justify my action.

My observations, upon which the following methods are based,have extended over a period of more than seven years.

At the beginning of this time my interest in this subject was arousedby the most conscientious and enthusiastic work Prof. Chr. Fenger wasdoing in this direction in the Cook County Hospital. The followingyear, while Interne in the Presbyterian Hospital, Prof. Moses Gunnkindly permitted me to apply my ideas in all of his operations anddressings, with the remarkable result of only two instances of suppura-tion in cases of wounds for non-suppurative conditions throughout myentire service under this brilliant surgeon.

While studying in Europe during the following two years I care-fully observed the methods employed, particularly in the clinics ofProfs. Billroth, Albert and Braun in Vienna, Kronlein in Zurich, v.Bergmann, Hahn, Bardeleben, Olshausen and Martin in Berlin, andSchede in Hamburg.

Upon returning to Chicago, Prof. Chas. T. Parkes, with whom Ihad visited the above and other clinics in Europe, kindly gave me themanagement of antiseptic methods in connection with all of his opera-tions and dressings in his clinical and hospital as well as in his privatepractice. I have preserved accurate notes concerning the progress of

Read before the Chicago Medical Society, May 16th, 1892.

2

each one of the hundreds of wounds in the management of which Ihad the good fortune to assist this great surgeon.

Unfortunately, the time allotted to each paper is too short topermit the use of abstracts from these notes, as I had intended. Iwill, however, state that primary union was the rule and suppurationthe rare exception.

For the past year I have had the privilege of assisting Prof. N.Senn in the care of all of his cases during and after his operations inthe Surgical Clinic at Rush Medical College and at the PresbyterianHospital, thus adding many valuable observations in this most im-portant subject.

Such favorable opportunities for studying methods and resultswould, I think, justify me in describing the methods which I havechosen, not only from the study of theory, but from their value inpractice, and which I apply in my surgical work, notwithstanding thefact that there is nothing new in these methods.

Antiseptic surgery has experienced three distinct epochs, thefirst consisting in the discovery of the principle by Sir Joseph Lister,and the time following, during which various antiseptic substanceswere employed empirically; the second beginning with the accuratescientific observations introduced by Prof. R. Koch, determining thepower of various antiseptic substances when applied in culture media,demonstrating the strength of solutions necessary to retard or obstructthe growth of the different bacteria; and the third epoch comprisingthe present time when antiseptic methods are used by most operatorsonly to the extent of securing aseptic conditions.

This plan has been advocated for some time by many of those mostexperienced in the practice of surgery, but it was almost as difficult tochange from antiseptic to aseptic methods as it had been to changefrom septic to antiseptic methods.

The studies of Geppert, which showed that all previous observationswith the most powerful one of the antiseptic substances, —corrosivesublimate—had contained a fatal error, impressed observers more thor-oughly with the idea that studies made in the test-tube cannot safelybe applied to surgical operations, and this has had much to do withbringing about the present tendency toward aseptic surgery.

It would be useless to attempt a review of all of the importantpapers which have appeared since 1867, dealing directly with thissubject. My own reading has covered more than one hundred of these,and I know of nearly twice as many others which I have not had anopportunity to read.

3

I will therefore not occupy your time with these reviews, but willlimit myself to a description of the methods which I follow in my ownpractice, and as an illustration of these methods and their results, Ihave tabulated abstracts of histories of all cases operated upon by my-self for non-suppurative conditions during the past twelve months inthe Augustana Hospital of this city, in which I have had the entirecontrol of the surgical work. I do not include orthopaedic operationsin which no wounds were produced, or in which the wounds weremade subcutaneously, nor cases which were treated by hypodermicinjections. Neither do I include operations in the mouth, in the nasalcavity, in the vagina, or bladder, or rectum, because it has beenrepeatedly proven that there is neither a possibility nor a necessity fordestroying all of the micro-organisms in these locations previous tooperations. In order to give a clearer idea of the plan followed I willdescribe the different steps taken;

Preparation oe Hands. My own hands and those of my assistantand the nurse who handles the sponges are washed thoroughly withordinary good white soap in warm, running water, with a scrubbingbrush. The finger-nails are cleaned with a pen-knife, and then thehands are washed once more in the same manner. They are thendried on a clean towel and then washed with one-half to one ounce ofstrong alcohol.

After the hands are washed in this manner, they never touch any-thing except the instruments or ligatures, the sponges or the wound,and to this simple fact I attribute the complete absence of suppurationor sepsis in a large number of successive cases.

My observations have taught me that it is a very simple matter toget everything surgically clean before an operation, but an exceed-ingly difficult matter to prevent the operator or his assistants, or thenurse, from handling something during the operation which directlyor indirectly brings septic matter in contact with the wound.

As a rule my own hands alone come in contact with the wound, inorder to fix the responsibility. The assistant aids by means of retract-ors or other instruments. A basin of warm water is placed on a standconveniently near for washing my hands. This water is changed fre-quently by a nurse who does not handle anything which is useddirectly in the operation.

In order to eliminate a frequent cause of infection, I never toucha suppurating wound, or a soiled dressing, or pus from any source, ifI can possibly avoid it, either in operations or in dressing wounds;and when there are several operations on the same day, I always

4

arrange them so as to do those for non-suppurative conditions first.It is a rule with me, never to dress any case immediately before oper-ating. I have often observed, that if a surgeon is in the habit of con-stantly getting his fingers into pus, his assistants are sure to imitatehim in this particular, but they are slow to learn the necessity of fol-lowing this bad practice by a thorough process of disinfection.

Caee of Instruments. The instruments are placed in a cleanplatter, either dry or in hot water, or hot two per cent, carbolic acidsolution, simply to keep them clean, not with any idea of disinfection.During the operation they are never placed upon anything which isnot covered with a clean towel.

After the operation the instruments are washed carefully inseveral changes of soap and hot water. They are always dried out ofwater at or near the boiling point in order to thoroughly dry thejoints. They are then preserved in clean canvas cases.

If the instruments have come in contact with pus they are boiledin a closed vessel for twenty minutes in water, with the addition of atablespoonful of baking soda to the quart of water, the soda preventingthe formation of rust.

An instrument which has become rusty is at once replated. Thisincurs but a slight expense, and it is easier to see dirt on a plated thanon a rusty instrument.

Sponges. The sponges used consist of absorbent cotton rolledbetween the hands into convenient bunches, wrung out of boiled waterimmediately before the operation. These sponges are always applieddry, there being simply enough moisture to prevent the adhesion ofcotton fibres to the wound.

In abdominal sections we use sea-sponges which have been thor-oughly cleaned by repeated washings in pure warm water and thenpreserved in five per cent, solution of carbolic acid. If any of thesesponges come in contact with pus they are permanently discarded.

Sutures. Both silk and cat-gut sutures are employed; the formerare boiled in water for an hour and then preserved in a five per cent,watery solution of carbolic acid.

The cat-gut is de-fatted for several days in ether, then placed infive per cent, carbolic acid in water for forty-eight hours and preservedin 1-1000 corrosive sublimate in strong alcohol.

Cat-gut sutures and ligatures are kept in strong alcohol duringthe operation to prevent them from swelling. Silk sutures are im-mersed in boiled water.

Preparation of the Operating Boom. Owing to a lack of spacein the present building I operate in any one of the twelve rooms andwards of the hospital, not considering it necessary to remove the furni-ture, nor especially to cleanse floors and walls.

An operating table is placed near a window, a small table to oneside for the instruments, ligatures and sutures, another one upon theother side for the sponges. All are covered with freshly laundriedsheets or towels. The patient is placed upon the table, preferablybefore the administration of the anaesthetic. Everything is in readi-ness., and from this time until the wound is dressed nothing is dis-turbed in the room, and any instrument, sponge or suture which hastouched anything not jwotected by clean towels is discarded for theentire operation.

The patient receives a full bath with soap and water and acathartic the day before the operation; he is also limited to a light dietduring this day. This practically disposes of causes of infection fromthe skin and the alimentary canal. The patient receives no breakfaston the morning of the operation, which takes place at 8 a. m. in thishospital.

Immediately before the operation the surface is washed thoroughlywith soap and warm water, then shaved, then washed again withwater, and then with strong alcohol.

This disposes of the dirt, the loose epidermis, the hair and thefat, and leaves the skin clean and dry, and not irritated. A piece ofgauze saturated with strong alcohol is left in contact with the surfacefor a minute or two before an incision is made. The field of operationis surrounded by dry, freshly-laundried towels. The operation isalways performed with the greatest amount of speed compatible withthe greatest care. The tissues are manipulated gently, in order toprevent tearing, crushing, or bruising. The wound is held open withretractors for the same reason. Hemorrhage is controlled thoroughly,by means of catgut ligatures or by pressure.

In suturing, care is taken to bring the surfaces accurately togetherin order to avoid spaces and raw surfaces. Whenever a considerableamount of wound secretion is anticipated, the wound is either packedwith iodoform gauze, or a rubber drainage tube is applied. This,however, is seldom necessary because wounds treated in this wayrarely secrete much.

Three or four days after the operation the packing or the drainagetube is removed, and the surfaces are held in contact by the applica-tion of pads of gauze or cotton.

6

The dressing consists of ten per cent, of iodoform gauze, carbolatedgauze, and absorbent cotton held in place by roller bandages. Inwounds in which no drainage is expected, strips of iodoform gauze areapplied and held in position by flexible collodion painted along theiredges. No irrigation is employed, except in the presence of pus, andno antiseptic substance is applied to the wound.

When aseptic wounds are redressed, either for the purpose ofremoving drainage-tubes or sutures, or for the purpose of removingiodoform gauze packing and- tying secondary sutures, the surface issimply sponged off with strong alcohol, and no irrigation is employed.I have seen many aseptic wounds infected by irrigation and otherunnecessary manipulations at the first dressing. The dressing used isordinarily the same as the original dressing. If there is any redness,or a slight amount of infection, a moist dressing of a sat. sol. ofacetate of aluminium or a three per cent, carbolic acid dressing willusually relieve the condition at once.

The following are the histories mentioned:

7

Nameand

resi-dence.

©be <

Diagnosis.

Duration of disease.

Treatment.

Kesult.

Dateofadmission.

Dateof discharge.

MatildaC.,

Attica,Ind.

45

Epitheliomaupper

eyelid.6

mos.Removalofhalftheeyelid;

advised

a

secondaryplasticoperation

aftersixmonths.

Progressaseptic

throughout.Oct.30, 1891.Nov.20,

1891.

Mrs.M., Chicago.65

Epitheliomalowerlidof

righteye.

6

years.Y

shapedexcisionwiththree-

quarterinchbase;closureof

woundwithsilksutures.

Primaryunion.

July8,

1891.July13,

1891.

Chas.P.,Ironton,

Wis.56Seventeenyearsago

patient

hadfacebadlycrushed

ina

runaway,leavinga

fistulain

righteyelidand

theeyedestroyed.

Severalattemptsatclosingfistula

hadfailed.

17yrs.

Eviscerationofeyetoformstump

forartificial

eyeandclosureof

fistulaby

splittingthe

tissues

andunitingwiththree

rowsof

sutures.

Primaryunion;no

pus.

April15, 1891.

May2,

1891.

Oscar0., Chicago.8

Suppuratingdermoid

cyst

ofleftlowereyelid.

2

years.Excisionofentirecyst;closureof

woundwithsilksutures.

Primaryunion.Jan.22, 1892.

Feb.5,

1892.

BessieM.R., Waukesha, Wis.11

Congenitaldouble

nose.

Patientalsohassecond

toesdouble.

11yrs.

Longitudinalincision

through

nose,splitting

cartilageandre-

movalof

wedge-shapedportion.

Deepquilled

sutures,silksutures

forskin.

Deformitycorrected;

primaryunion.

June29, 1891.July14,

1891.

JohnG.,Kim

ball,S.

Dak.

11Cicatricialcontractionof

face,causingectropion

andcarryingthelowerlip

beneaththechin.

Four

yearsago

patientwas

burnedina

prairiefire.

4

years.Semilunarincision

beneatheach

eyelid.Implantationofskin

grafts

inch.Semilunar

incisionbeneaththechin,

dissec-

tionofcicatricialtissue.

Cover-

ingofrawsurfacewith

Thiersch’sskingrafts

4x6inches.

Healingthroughout;

patientcloses

mouthandeyes

normally.

Jan.27, 1892.April27,

1892.

ChristM.,Rockford,

111.26

Varicocele,severepain

and

nervoussymptoms.

2

years.Excisionof

enlargedveins.

Primaryunion.

July15, 1891.

Aug.1,

1891.

8

Nameandresi-

dence.Age.

Diagnosis.

Duration of disease.

Treatment.

Result.

Dateof admission.

Dateof discharge.

E.A.G.,Curry,

Wis.24

Varicocele;symptomsas

above.

8

years.Excisionofenlargedveins.

Primaryunion.June24, 1891.July4,

1891.

JamesW.,

St.Louis,Mo.

36

Varicocele;causedbyheavy

lifting.

8

years.Excisionofenlarged

veins.Some

irritationoccurredonfourthday

whichsubsidedupon

application

ofsat.sol.of

boricacidat

once.Primaryunion;no

riseof

temperature.June29, 1891.July7,

1891.

C.E.B., Iron

Moun-tain,Mich.

32

Hydroceleof

rightside;

causedby

traumatismsix-

teenyearsago.

Wastap-

pedandinjected

seven

yearsago.

16yrs.

Incision;attachmentoftunica

vag.toskin.

Thesacwas

found

tobecoveredwithsmalltuber-

cles.Cauterizationwithstrong

carbolicacid.

Packingwith

iodoformgauze.

Thiswas

re-

movedon

fifthday

andre-

packed.

Healingfromthe

bottomby

granula-tion.Woundbe-

cameinfectedtwo

weeksafter

opera-

tion.

Jan,18, 1892.

Feb.24,

1892.

Mrs.C.A.A.,

Ga1esburg,

111.

35

Lipomaofneckaslargeas

achild’shand.

2

years.Enucleation;

closureofwoundwith

catgut.

Onedressing;

prim-

aryunion.

April25, 1891.May3,

1891.

EmmaJ., Chicago.25

Lipomaoflabiummaj.as

largeastwofists.

30mos.

Enucleation;closureofwound

throughoutwithcat-gutsutures.

Primaryunion;

one

dressing.

Aug.10, 1891.

Aug.19,

1891,

CharlotteE., Geneseo,

111.40

Angiolipomaas

largeasa

handover

seventhribin

lumbarregion.

1

year.Removal;

closedwithdeep

and

superficialsilksutures.

Primaryunion;one

dressing.

May31, 1891.

Sept.12,

1891.

MollyL.,Laporte,

Ind.10

Congenitallipomataof

rightaxillaandleftside,

eachaslargeasa

hand.10yrs.

Removal;appliediodoform

gauze

packingto

overcomeoozing,

permittingittoprojectthrough

anopeningintheskin.Closed

woundthroughout;

removedpackingthirdday

andapplied

padtocoaptsurfaces.

Primaryunion;two

dressings.

Nov.16,

1891.Dec.2,

1892.

9

AugustaA,, Chicago,20

Adenomaofleftbreastas

largeasa

walnut.

Noticed 4weeks ago.Enucleation;

closureofwound

withcatgutsutures.

Primaryunion;one

dressing.

Aug.25, 1891.

Aug.28, 1891.Returned fordress- ingSept.

i.

Mrs.F.Sp., Chicago.29

Fibroadenomaofleftbreast

aslargeasa

smallhand.

6

years.Removalofbreast;closureofwound

withsilksuture;

rubberdrain.

Primaryunion;two

dressings.

Feb.16, 1892.

Feb.28,

1892.

MissM.E.L.,

Aurora,111.

40Carcinomaof

rightbreast.8

years.Removalof

entirebreasttogether

withaxillary

glandsandfat

on

fasciaof

pectoralismajor

muscle.

Primaryunion.This

patientdeveloped

typhoidfeverafter

twoweeks,from

whichshe-

recover-ed.Thewoundre-

mainednormal.

April19, 1891.

May28,

1892.

Mrs.E.A.N., Hennepin,

111.62

Carcinomaof

rightbreast;

thetumorbeing

adherentto

pectoralismajor,m.

8mos.

Operationthe

sameasin

previous

case.Removalofa

portionof

pectoralismajor

muscle;axilla

packedwith

gauze,whichwas

removedon

fifthday.

Primaryunion.

i

May3,

1891.May24,

1891.

Mrs.C.S., Altona,

111.

56Carcinomaof

rightbreast,

involvingaxillary

glands.7

mos.Operationthe

sameasabovewithout

theremovalofa

partofthemuscle.

Primaryunion.

Sept.22, 1891.

Oct.16,

1891.

Mrs.A.S.H.,Evanston,

111.56Carcinoma

rightbreast,in-

volvingaxillary

glands;

ulceratedsinceeight

months.

2

years.Operationthe

sameasabove,but

theamountofskin

removedwas

•muchgreater.

Woundhealedprim-

arilyexceptwhere

tensionsuturescut;

atthese

pointsit

healedby

granula-tion,

remainingaseptic

throughout.Oct.5,

1891.Oct.27,

1891.

Mrs.W.E.H., Woodstock,

111.44:

Carcinomarightbreast.•

1

year.Sameoperation.

Primaryunion.Nov.3,

1891.Nov.22,

1891.

Geo.J., South

Bend,Ind.

6

Rightinguinalhernia.2

years.Bassinis’

operationfor

radical

cure,collodion

dressing.

Twodressings;

prim-

aryunion;opening

closedfirmly.

Nov.17, 1891.

Dec.16, 1891.

AndrewL.,Rockford,

111.50

Rightinguinalhernia.3

years.The

sameoperation.

Primaryunion;one

dressing.

Jan,28, 1892,

Feb.20,

1892,

10

Nameandresi-

dence.tUD

Diagnosis.

Duration of disease.

Treatment.

Result.

Dateofadmission.

Dateof discharge.

Mrs.M.A.B.,

Chicago.30

Rightfemoralhernia.5

years.Incisioninto

sac;omentum

adherentto

sacandfemoral

ring.Looseningofomentum

andresectionof

largepiece.

Closureofwoundwithfour

rows

ofcatgutsutures.

Primaryunion;

one

dressing.

Mar.20, 1892.

April7,

1892,

CarlL.P.,

Cable,111.

69Tuberculosisof

knee.Pa-

tient’sgeneral

conditionmuch

reducedfromlong

continuedseverepain.

2

years.Amputationof

thighatlower

thirdlong

anterior;shortpos-

teriorflap;catgutsutures;no

drainage.

Primaryunion;two

dressings.

Aug.17, 1891.

Sept.15, 1891.

AbnerM., Chicago.77Chronicinflammationof

tendonsof

lefthand,

anchylosisofwrist

andall

ofthe

jointsofhandand

fingers.Asinusextends

throughcenterofhand.

Constantsevere

pain;has

undergoneseveralopera-

tions.

2

years.Amputationatlowerthird;modi-

fiedcircularflap;

nodrainage;

catgutsutures.

Primaryunion;two

dressings.

March4,

1892,Mar.13, 1892.

PeterE.,Monmouth, 111.43

Deformityaftercompound

Pott’sfractureofleftleg;

faultyunion;markedde-

formity;patienthasnot

beenabletowalk.

14mos.

Curettingof

ulcer;longitudinal

incisionover

surfaceofinner

maleolus;osteotomy

excisionof

wedgeshapedpieceofbonewith

oneanda

halfinchbase;closure

ofwoundwithcatgut

sutures;

nodrainage;

applicationof

plaster-of-pariscast.

Primaryunion

throughout;legand

heelwas

coveredwith

blistersatfirst

dressing,possibly

theresultofvigor-

ousscrubbing;posi-

tionperfect.

Nov.30, 1891.

Feb.23, 1892.

ClemR.S., Chicago.23

Faultyunionoftibia

and

fibulaatlowerthirdafter

compoundfracture.Pa-

tientfeelspainatpointof

fractureandinhollowof

foot.

2/ijyrs.

Operationthe

sameasabove.

Primaryunion;per-

fectposition;pa-

tientisto

remainunderobservation

fortenweeks.

April7,

1892.April28, 1892.

11

IdaM.,

Ga1esburg,

111.

20Tubercularglandsofthe

leftsideofneck,

super-

ficialanddeep,

extendingfromangleof

jawto

clavicle.

3

years.Free

incision;removalofglands;

irrigationwithiodinewater;

packingwithiodoform

gauze;

secondarysutures;

removedpackingon

fifthday

andtied

sutures.

Woundhealed throughout

withoutsuppuration.

July21, 1891.Aug.5

1891.

Mrs.J.L.,Chicago.30

Tuberculosisof

superficialanddeep

cervicalglands

leftside.

6mos.

Removalofallglandsthrougha

largeincisionfromangleofjaw

toclavicle,includingkrjverhalf

of

parotidgland;

iodoform

gauzepacking,etc.,as

above.Woundhealed throughout

withoutsuppuration.

MarchS, 1892.April7

1892.

HedwigE.,Ravenswood, 111.15

Tuberculosisofdeep

cervi-

callymphaticglands,in-

creasingrapidlyinsize

andnumberoflate.

7

years.Extirpationof

gland;irrigation

withiodinewater;closureof

woundwithcatgutsutures

throughout.

Woundhealed

primarilythrough-

out.

Mar.13, 1892,

Mar.27

1892.

MissNettieC.,

Racine,Wis.

26Chronicpelvic

peritonitis;repeatedpelvicabscesses;

patientconfinedtobed

formonths.

1

year.Abdominal

section;foundintes-

tinesadherenttoeachother,to

pelvicorgans,andto

abdominalwall;loosened

adhesions;freely

drainedcavitywithglassdrain,

whichI

removedon

fourthday;

openedintestineatpointof

adhesion;closedwithtwo

rows

ofsutures.

Normalrecovery;pa-

tienthasgained

twentypoundssince

andis

perfectlywell.

April10, 1892.

May21

1892.

Mrs.MathildaB.

DeKalb,

111.38Chronic

inflammationof

theleft

ovary;patienthas

beentreated

repeatedlyin

severalhospitalsbutwith-

outbenefit;hasbeen

con-

finedtobedfortwoyears.

5

years.Ovariotomyandbreaking

upof

oldadhesions.

Primaryunion

normalthrough-

out.

June27, 1891.July21

1891.

Mrs.S.J.,

LakeView.

37Chronicinflammationof

ovaries.Hasbeenin

anotherhospitaltwicefor

severalmonths,eachtime

withoutbenefit.

Confinedto

bedfor

morethanone

year.

7

years.Ovariotomy

sameasabove.

Primaryunion.Nov.28, 1891.Jan.19

1892.

12

Nameand

resi-dence.

Diagnosis.

Duration of disease.

Treatment.

Result.

Dateof admission.

Dateof discharge.

MissBerthaH.,

Chicago.16

Papillomatousovariancyst

weighingthirtypounds

adherenttomesocolon,to

abdominalwall,

floorof

pelvisand

omentum.2

years.Removal;

Miculicz’sdrainage;

packingremovedinthreepor-

tionson

fifth,seventh,

andninth

day.

Primaryunion

ex-

ceptat

pointof

drainage;normal

throughout.Feb.6, 1892.March5,

1892.

Mrs.LouiseS., Watertown, Wis.69

Tubercularperitonitis,

originatinginleft

ovary

ortube;

abdomencon-

tainedthirtypintsof

fluid.

7mos.

Abdominalsection,

removalof

fluid;removalofleft

ovaryand

tube;largeglassdrain

leftin

positionfortwoweeks.

Primaryunionex-

ceptat

pointof

drainagetube.

Aug.22, 1891.Sept.15,

1891.

HelenM., Geneva,

111.16

Tubercularperitonitis;

twenty-fivepintsof

yellowishfluid.

1

year.Abdominalsection,emptying

cavitycompletely;largeglass

drain.

Thesameas

above.May22, 1891.July2,

1891.

IdaN., Chicago.16

Tubercularperitonitis;

twentypintsoffluid.

2

years.Operationthe

sameasabove.The

sameasabove.April5,

1892.April23,

1892.

Mrs.AnnaR.,

Chicago.43

•Uterine

fibroidaslargeas

achild’sheadinthepos-

teriorportionofthebody

oftheuterus,

andanother

oneofequalsize

attachedtotheformerbya

finger-

likepedicle;

suffersseverelyfrom

pressurecausedbythe

verymov-

ablefibroid

2

years.Ligationof

broadligaments

on

bothsides;ligationofuterine

arteries;applicationof

rubber

ligaturearoundcervix;

removal

of

portiononeinch

aboveliga-

ture;cauterizationofcervical

canalwith

Paqnelincautery;

closureof

abdominalwoundwith

silksutures.

Primaryunion;

dressedon

ninth

dayto

removethestitchesand

rubberligature;

dressedwoundoncea

week

untildischarged.

Mar.21, 1892.April25,

1892.

Mrs.LouiseW.,

Chicago.63Sarcomaof

rightkidney

as

largeasa

child’shead.*

*Thiscasewas

reportedindetail

totheChicagoMedicalSociety,

November2,1891.

14mos.

Nephrectomyby

abdominalsec-

tion.

Normalrecovery;

primaryunion

ex-

ceptat

pointof

drainage.

Aug.22, 1891.Sept.28,

1891.

13

Mrs.John

P.,

Altoona,111.

39Patienthastwo

slightly

irregular,hard

abdominaltumors,

slightlymovable.

Theurine

containsa,

traceof

albumen;mens-

truationhasbeenirregular

forten

months.

10mos.

Exploratoryabdominalsection,

demonstratingthe

presenceof

multilocularcystsof

bothkid-

neys;closureof

woundwith

deepsutures.

Normalrecovery;

primaryunion.

Oct.17, 1891.

t

Nov.6,

1891.

MissJosephine

S.,De

Kalb,111.

17

Duringthepasttwo

and

onehalfyears

patienthas

hadfive

attacksof

peri-

tonitisoriginatingin

the

rightiliac

region,with

.characteristicsymptoms

ofacute

appendicitis.The

lastattack,threemonths

ago,was

especiallysevere,

andleavinga

distinct

pointofhardnessand

tendernessinthis

region.2

yrs.Longitudinal

incisionover

ccecum;looseningof

numerousadhesionsbetweenomentum

and

ccecumandilium;ligationof

mesenteryof

appendixandliga-

tionof

appendixwithsilk;

cau-

terizationofitslumenwith

strongcarbolic

acid.Thelumen

ofthe

appendixwas

foundoc-

cludedhalfan

inchfromits

origin;closureof

entirewound.

Normalrecovery;

primaryunion.

Jan.6, 1892.

i

Jan.27,

1892.

GeorgeJL,

LaValle,

Wis,33Overtwo

yearsagoI

re-

movedsixinchesofpa-

tient’srectumby

meansof

resectionof

sacrumandcoccyx

(Kraske’sopera-

tion);

havinga

recurrenceofthetumorinthesig-

moid,whichI

removedwiththe

Paquelincautery

twoweeksago.Astricture

istobe

expected.

4

years. iMaydl’singuinal

colostomy;incis-

ionparallelwiththefibresof

theexternalobliquemuscleof

abdomenthree

incheslonginthe

leftinguinal

region;separation

offibresofexternal

oblique

andalsoofinternal

oblique;

incisionthrough

transversalisfasciaand

peritoneum;attach-

mentof

peritoneumtoskin;

sigmoidflexure

broughtup

into

thewound;aglass

rodcovered

withiodoform

gauzepassed

throughmesocolonandper-

mittedtoprojectbeyondwound

ofabdominalwall.Transverse

incisionthroughcolonon

third

day,leaving

posteriorwall.

Patientsufferedfrom

painuntiltheintes-

tinewas

opened;the

temperatureneverexceeded100°

F.

May28, 1891,June13

1891.

14

Nameand

resi-dence.

Age.

Diagnosis.

Duration of disease.

Treatment.

Result.

Dateof admission.

Dateof discharge.

Mrs.C.G.A., Galesburg,

111.

47Aneurismof

rightvertebral

arteryas

largeasan

orange,causedbya

blow

froma

baseball.4

years.Removal

througha

longitudinalincision;controlledhemorrhage

withlong-jawedforcepsand

tamponing;closed

remainderof

woundwithdeepsilksutures.

Primaryunion

ex-

ceptatpointof

forceps;there

secondaryunion;

removedforceps

afterfor

ty-eighthours.

Feb.17, 1892.

Mar.22,

1892.

Mr.W.A.F., Whitewater, Wis.

23Loosened

fracturedsemi-

lunarcartilageof

right

kneeafterinjury.

2

years.Longitudinal

incisionoverex-

ternalcondyle;

removalof

car-

tilage;closureofwoundwith

threerowsof

catgutsutures;

plaster-of-pariscast.

Primaryunion;

one

dressing.

Mar.2, 1892.April17,

1892.

JohnS., Chicago.43Varicoseulcerof

rightleg;

internalsurface.

7

years.Excisionofthreeinchesofthe

internalsaphenousvein;

kept

limbelevatedforfourweeks.

Primaryunion;two

dressings.

Jan.6, 1892.

Feb.2,

1892.

OscarJ.,

DeKalb,

111.11

Tuberculosisof

hip-joint;

destructionofneckof

femur;hadbeentreated

foreightmonthswith

extensionand

immobiliza-tionwithout

benefit.8

mos.Resectionofhip;packingof

cavitywithiodoform

gauze;ap-

pliedsecondarysutures;

oneweek

laterremoved

packing;iodo-

formizedthecavityandpacked

itwith

decalcifiedbonechips

andtied

secondarysutures

and

appliedplastercast;changed

dressingagainafterfourweeks.

Later,Buck’s

extensionwas

applied.

Woundunitedwith

exceptionofa

smallsuperficialpoint;

extensiontobe

con-

tinuedfor

oneyear

at

night;nosup-

puration.

Sep.15, 1891,Jan.29,

1892.

15

This table contains abstracts of the histories of forty-seven con-secutive operations for nonsuppurative conditions upon nearly everyportion of the body, and varying in severity from a simple incision tooperations of the gravest character.

These operations having been performed in the same hospital andwith the same precautions, their number is sufficient, I think, to estab-lish the efficacy of the method.

Of course I have operated during this time upon many cases suf-fering from conditions complicated with suppuration before the opera-tion, with equally good results, but this paper is already too long, anda further addition of histories would simply increase this fault, so Iwill reserve these for a future paper.

For the sake of convenience I have arranged these histories ingroups of similar cases. The first group comprises seven operationsof various characters upon the face, all of which recovered rapidly, andwithout suppuration. The second group contains operations upon thescrotum. In three cases excision of enlarged veins in varicocele wasmade; in the fourth case I treated a tubercular hydrocele by open in-cision, packing the cavity with iodoform gauze. The cavity becameinfected two weeks after the operation. There had been severe itch-ing, which the patient had tried to relieve by inserting his fingerbeneath the dressing and scratching the skin. This is the only case inthis entire list which became infected, and here it is quite apparentthat the cause of infection was in no way connected with the operation.

The third group comprises six non-malignant tumors, most ofthem being of a considerable size. All of these wounds healed pri-marily, four of them with one and two with two dressings; in the latterthe first dressing was made to remove the drainage and the second toremove the sutures. These patients were in the hospital ten days onan average.

The fourth group contains five cases of cancer of the breast. Ineach case the entire breast, together with the fascia of the pectoralismajor and the fat and lymphatic glands of the axilla, were removed.All wounds healed primarily except the fourth, in which the tumor hadulcerated, necessitating the removal of a very large amount of skin.In this case the tension sutures destroyed a small amount of skin,which healed by granulation.

Case one was peculiar in that she developed typhoid fever twoweeks after the operation. The wound was entirely healed, and wasnot influenced by the typhoid fever. The patient recovered normally.These patients remained in the hospital about three weeks each.

The fifth group consists of three herniotomies, each one of whichhealed primarily. The patients remained in the hospital four, three,.

16

and two and one-half weeks respectively. The first case, a boy of sixyears, was kept longer than the other cases, because I desired to pre-vent an accident to the scar, with possible recurrence, through someimprudence of the child.

The sixth group contains two amputations; one of the thigh, andone of the forearm, both without drainage, and both healing pri-marily. The first case was in the hospital four weeks, being kept twoweeks after his stump had healed, in order to build up his generalcondition, which was much reduced at the time of the operation; thesecond case was in the hospital nine days.

The seventh group consists of two cuneiform osteotomies of thetibia for faulty union of compound fractures of the leg, which healedprimarily.

The eighth group has three cases in which I removed superficialand deep tubercular glands of the neck, extending from the angle ofthe jaw to the clavicle. The wounds were treated by the use of iodo-form gauze packing and secondary sutures; the packing was removedand the sutures tied on the fifth day. These cases healed without theoccurrence of pus, from two to four weeks.

The ninth group comprises twelve abdominal sections. All ofthese cases recovered, and in each one the abdominal wound, varyingfrom three to twelve inches in length, healed primarily.

These sections were performed for the following conditions; InCase I. the intestines and the pelvic organs were adherent to each otherand to the abdominal walls, causing severe pain, so that the patient hadto be confined to bed for months. These adhesions were loosened, aglass drainage tube was introduced and left in place for four, days.The next two cases were simple ovariotomies for the relief of pain dueto pressure upon the ovaries by old adhesions. Case IV., a papillo-matous ovarian cyst weighing thirty pounds and adherent to the ab-dominal wall, to the floor of the pelvis, to the mesocolon, and theomentum, in a girl sixteen years of age, required an incision extendingfrom the ensiform appendix of the sternum to the symphesis pubis.The wound healed primarily throughout except at the point of drain-age, the patient’s temperature remaining below 100° F.,the same as inthe simple ovariotomies.

Cases V., VI. and YII. were operated for the relief of an enormousdistension of the abdomen with fluid caused by the presence of tuber-culosis of the peritoneum, originating apparently in each case in theleft fallopian tube. Each one of these cases recovered without a signof pus infection.

Case VIII. A fibrorayoma of the posterior uterine wall and apediculated fibroid from the fundus, each as large as a child’s head,

17

was treated by the use of an external pedicle. The patient recoveredwithout a sign of shock or temperature, and without suppuration,requiring only four dressings.

Case IX. A sarcoma of the kidney as large as a child’s head wastreated by means of nephrectomy through an abdominal incision.Here again there was primary union except at the point of the drain-age-tubes. In case X. an exploratory laparotomy showed the presenceof double multilocular cyst of the kidneys; the wound healed primarily,the patient leaving the hospital twenty days after her admission.

Case XI. in which I removed the vermiform appendix becausethe patient’s life had been in danger several times from recurrentsevere attacks of appendicitis, recovered with primary union of thewound throughout, leaving the hospital three weeks from the time ofadmission.

Case XII. An inguinal colostomy according to Maydl’s methodleft the hospital two weeks after the operation, having been normalthroughout.

In the tenth group we have the remaining four miscellaneouscases. 1. Enucleation of an aneurism of the right vertebral artery aslarge as an orange; 2. removal of a fractured semilunar cartilage; 3.excision of three inches of the internal saphenous vein for the relief ofa varicose ulcer. Each of these three cases healed without suppura-tion.

The fourth case, a resection of the hip, was treated by means ofwhat appears to me to be a novel method. A typical resection wasmade through the neck of the femur. The tubercular synovial mem-brane was carefully dissected out; every particle of suspicious tissuewas removed. The cavity was then irrigated with a solution of tr. ofiodine in water the color of sherry, then dried and thoroughly rubbedwith iodoform, then packed with iodoform gauzeand secondary suturesapplied. One week later the packing was removed; the cavity oncemore dusted with iodoform and filled with Senn’s decalcified bone chipsthoroughly rubbed with iodoform. Over these the secondary suturesof silk-worm-gut were tied and a plaster-of-paris cast applied overthe usual dressing. The wound remained aseptic, the dressing waschanged and the stitches removed after three weeks. The woundhad healed throughout, except at the point of the stitches. There wasno pus. After this extension was applied for orthopaedic purposes,giving the patient but slight shortening and a very good position forthe limb.

A study of these abstracts, in which I wish to direct your atten-tion particularly to the short time each patient was confined to thehospital, will speak for the value of the method employed.

18

It is extremely simple. It does not annoy the patient or thesurgeon unnecessarily. It is inexpensive and requires only such thingsas any one can readily procure.

To secure an aseptic condition of the wound after any operationfor a non-suppurative condition, it is but necessary to have soap andboiled water, a scrubbing-brush, a pint of strong alcohol, a pound ofclean absorbent cotton, a can of commercial sterilized or antisepticgauze and a number of freshly laundried towels.

Of course I do not attribute the rapid and satisfactory recoveryof these patients entirely to the methods employed. Much of this isdue to the excellent care the patients received from the able andenthusiastic nurses of this hospital

Literature. I had collected a list of articles bearing upon thissubject, when the valuable book on aseptic surgery by Schimmelbusch(Aseptische Wundbehandlung Schimmelbusch, August Hirschwald,Berlin) appeared containing a much more complete list, so I will referthose interested to that work.

710 Sedgwick Street.

Practical ideas on antiseptic and aseptic methods in the treatment of wounds :FRONTCover page

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