Introduction and Background

Stuphytococeus pyogenes aureus. Fig. 2. Streptococes pyogenes, Gonococens, Fie, 4, Micrococeus lanceolatus, Fig. a ie Bacillus coli communis. Fig. 6. ats, os i ich SM, tne Bacillus pyoeyaneus F ora ne 7 & Are Me Bacillus tetni. Fic. 8. Sat>, VO ty PIBY ty Bacillng tuberculosis. ASEPTIC SURGICAL TECHNIQUE With Especial Reference to Gynecological Operations, together with Notes on the Technique Employed in Certain Supplementary Procedures BY HUNTER ROBB, M.D. PROFESSOR OF GYNAECOLOGY, WESTEGM RESERVE UNIVERSITY ; GYNAICOLO- GIST-IN-CHIEF TO THE LAKESIDE HOSPITAL, CLEVELAND, OHIO; FELLOW OF THE AMERICAN GYNACOLOGICAL SOCIETY, BTC. ILLUSTRATED - FOURTH EDITION, REVISED PHILADELPHIA J. B. LIPPINCOTT COMPANY 1906 r Copyright, 18%, by J. B. LirPiNcorr ComPANY Copyright, 1901, by J. B. Liprincorr Company. Copyright, 1902, by Huwrer Rone Copyright, 1906, by Huwrten Ro ELECTROTYPED AND PRINTED BY J. B. LIPPINCOTT COMPANY, PHILADELPHIA, U.8.A. -AZ Vos oVvLT TO HOWARD A. KELLY PROFESSOR OF GYNECOLOGY, JOHNS HOPKINS UNIVERSITY 9 ow PREFACE TO THE THIRD EDITION, REVISED. In the revised third edition of this book the majority of the changes deal with certain modifica- tions that we have found practicable and consistent in the technique of operative work. Several new and original illustrations have also been added. Honrsr Ross. CLEVELAND, May, 1906. PREFACE TO THE FIRST EDITION. Iw preparing this book I have availed myself of the writings of my predecessors in this field, and have gathered much from their work, especially from that of Schimmelbusch, Terrillon, and Singer. The tech- nique recommended is in the main that practised in the gynecological and surgical departments of the Johns Hopkins Hospital. I have to express my sincere thanks to Professor Welch, to Dr. L. F. Barker, and others for kind sug- gestions, and to Dr. F. R. Smith for the revision of the manuscript. Bartimore, June, 1894. vii CONTENTS. CHAPTER IL Importance to the surgeon of s bacteriological training— Sepsis and ‘ound dation Mian ongations concerned —Asopsis—Antiseptis. ee CHAPTER IL Principles of sterilization—Dry and moist heat—Fractional sterilization—Chemical disinfection. . . . . sec ee CHAPTER III. Practical application of the principles of sterilization—Oper- ating sult—Preparation of the surgeon and his assist- CHAPTER IV. The preparation of patients for operations, major and minor —Means employed to obtain an aseptic field... . . CHAPTER V. Gynwcological instruments—Methods of sterilization—In- strument traye—Care of the instruments after operations CHAPTER VI. Aseptic sutures, ligatures, and carrierse—Suture materiale— Sterilization and preservation of the various kinds . . . racE 91-103 ix x CONTENTS. CHAPTER VII. Sterilized dressings—Cotton—Gauzes—Bandages—Tampons Sponges... 0... ee rrr tt . CHAPTER VIII. Aseptic drainage—Glass and rubber drainage-tubes—Gauze drains—Care of rubber muterials—Rubber dam—Rubber tubing—Rubber gloves and armlets CHAPTER IX. Fluids for irrigation—Plain sterile water—Antiseptic fluids for irrigation—Sterile physiological salt. solution—Anti- septic powders—Iodoformized oil—Bichloride celloidin— Iodoformized celloidin—Silver foil—Gutta-percha. . . CHAPTER Xx. On certain procedures sometimes necessary before and after operations, which must be conducted aseptically—Hypo- dermic injeotions—Exploratory punctures—Catheteriza- tion—Bladder-washing—Ureteral catheterization... CHAPTER XI. ‘The gynecological operating-room—Operating-table—Instru- ment-cases and other furnishings... . . . fee CHAPTER XII. The organization of operations—The maintenance of an aseptic technique during operations .......... CHAPTER XIII. Post-operative care—Position in bed—Diet—Vomiting— Rectal feeding—Shock—Pain and restlessness—Con- stipation—Catheterization—Convalescence—Removal of stitches—Dressings subsequent to operations—Hemor- rhage—Intestinal obstruction—Infection ... 2... 104-114 116-127 128-189 140-147 148-159 160-177 CONTENTS. xl CHAPTER XIV. Operations in the country, in private houses, or in other places where the technique must necessarily be more or less imperfect—The armamentarium—An improvised operating-room—Modifications in technique... . . « 196-208 CHAPTER XV: Anesthesia as an aid to diagnosis: its importance in general surgery and gynmcology—Preparation of the patient— Position—Methods of examination—Rectal palpation. . 209-217 CHAPTER XVI. Bacteriological and clinical examinations in surgery and gynmoology 2... ee 218-227 CHAPTER XVII. ‘The examination of the interior of the female bladder, and the catheterization of the ureters... 2... ++. 228-287 CHAPTER XVIII. Pathological examinations»... ........ 5... 288-262 LIST OF ILLUSTRATIONS. PLATES. PAGE Pare L—Figures of eight different bacteria . . . Frontispiece Prarz I1—Sterilization of the hands with permanganate of potassium... . 1. rn Prare IIL —Fig. 1, Long dressing-forcops; Fig. 2, Drainage. tube forceps with Kelly’slock.. 2.0... 00005 Prarz IV.—Fig. 1, Hamostatic forceps ; Fig. 2, Bullet-forceps . Puare V.—Fig. 1, Rat-tooth forceps; Fig. 2, Curved = Fig. 8, Transfizion needles . Puarz VI—Fig. 1, Neodle-holder; Fig. 8, Retractor; Fig. 4,Scalpels. .. 2.2.0... Pare VIL—Fig. 1, Scissors; Fig. 2, Uterine sound; Fig, 8, Sims's speculum... .........- sees Piare VIIL.—Fig. 1, Trivalve speculum; Fig. 2, Sponge- holder; Fig. 8, Corrugated tenaculum ...... Pare IX.—Fig. 1, Trocar; Fig. 2, Nélaton’s forceps Prate X.—Fig. 1, Simon’s speculum ; Fig. 2, Curettes Prare XL—Fig. 1, Modified Goodell-Bllinger dilator, smallest size; Fig. 2, Hegar’s dilator; Fig. 8, Shot-compressor . . . Prare XII.—Fig. 1, Two-way catheter; Fig. 2, Chloroform- bottle; Fig. 8, Chloroform-inhsler; Fig. 4, Tenacula . . . Prare XITI.—Fig. 1, Glass dishes; Fig. 2, Sterilized towels in three-per-cent. carbolic solution; Fig. 8, Sterile cotton in glass jar; Fig. 4, Sponges in three-per-cent. carbolic solu- tion ; Fig. 5, Sterilized tampons in glass jar; Fig. 6, Steril- ized gatize in glass jar; Fig. 7, Ligatures in glass jar; Fig. 8, Gauze drains... 1... eee Puare XIV.—Fig. 1, Flasks for sterile salt solntion; Fig. 2, 56 69 70 "4 75 76 7 78 78 138 xiv LIST OF ILLUSTRATIONS. Prats XV.—Gynacological operating-room, Lakeside Hospital, Cleveland, Ohio... 2.2... Pare XVI—Fig. 1, Modifled operating-table for abdominal section; Fig. 2, Modified operating-table for plastic oper- TREE TET EO CREAT TS Pare XVII.—Modifed oporating-table, Trendelenburg position Pratz XVIII.—Glase-top table with metal supports, for instru- ments and basins Prare XXI.—Fig. 1, Hemostatic forceps strung on steel ring ; Fig. 2, Floating glass label; Fig. 8, Glass basins; Fig. 4, Cotton pledgets in glass bottles; Fig. 6, Agate-ware vessel, with top protected with gauze 2... 2... 2. ee Prare XXII.—Field of operation and the neighboring parts protected by gauze diaphragm, towels, and stockings Prats XXIII.—Examination under sheet PLate XXIV.—Hips in moderate elevation for cystoscopic ex- amination and direct catheterization of ureters. Cystoscopic and ureteral instruments on tray in foreground... . . Pirate XXV.—Fig. 1, Normal mucous membrane of the uterus (after Zweifel); Fig. 2, Chronic interstitial endometri (after Zweifel) RIGUBRS: Fie. 1.—Hot-air sterilizer . . . Fro. 2.—Steam sterilizer (Amol) Fia. 8—Steam sterilizer (Koch) . . Fro. 4.—Steam sterilizer (in section)... . 2. . Fie. 6.—Suits worn by operator and nurse... . Fic. 6.—Spigot attachment .......... . Fic. 7.—Robb’s aseptic razor, with case... . . Fro. 8.—Metal box for instruments Fic. 9.—Boiler for soda solution . . Fra. 10.—Improved boiler with basket containing instruments . Fras. 11, 12.—Basins for instruments... 2... i Fra. 18.—Aseptic ligature tray»... 0 ae Fra. 14.—Needle armed with carrier. 2... 6. 154 - 176 214 Sass SSRRRe LIST OF ILLUSTRATIONS. xv PAGE Fig. 15.—Glass reels for ligatures ©. - 2-2. ee 94 Fics. 16, 17.—Ignition test-tubes with ligatures on ist acces BE Fig. 18.—Sterilized catgut in sealed glass tubes . . . . « see 96 Fig, 18, a.—Tube of sterilized catgut ....-- 103 Fra. 19.—Modified Scultetus bandage . . . . . mM Fra. 20.—Sponge made of cotton and gauze . 12 Fro, 21.—Thermometer jar. 5... 0 es 132 Fig. 22 —Glass douche-nozzle ....... 184 Fra. 28.—Aseptic powder flask .. 2... 186 Fia. 24.—Glass catheter ©. 2.2... - 145 Fi. 25.—Glass catheters in one to twenty carbolic 146 Fro, 26.—Edison storage-battery lamp with a McCreary half- shade: vs 6 4 BER oe ORES ESE Fig, 27.—Kelly’s operating-table ..... . Fra. 28.—Halsted’s operating-table . . . . Fro. 20.—Halsted’s operating-table, showing perineal block in position... 2. eee 168 Fro, 80,—Halsted’s semicircular table for instruments . . . . . 154 Fro. 81.—Rubber ovariotomy-pad . . . Fic. 82.—Rubber ovariotomy-pad in position . Fic. 88.—Sponging out cul-de-sac... 1a. 84.—Removal of abdominal sutures . Fias. 86, 86.—Robb’s leg-holder. . . Fra. 87.—Hot-water can .. 2... Fria. 88.—Abdominal bandage .... . Fig. 89.—Canton-flannel sheet for instruments ... ~~. + + 198 Fic. 40.—Instruments wrapped in canton-flannel sheet. . . . . 199 Fic. 41.—Double urethral dilator... . Fro, 42.—Speculum and obturator Fra. 43.—Delicate mouse-toothed forceps . Fic. 44.—Ureteral catheters, without hundles, for direct catheter- ization through speculum... 2... se 281 Fro. 46.—Seetion through a blood-clot from the uterus after abor- tion, showing transverse and longitudinal sections of chori- onic villi (after Orth) 2... 1. ee ee 246 Fro. 46.—Adeno-carcinoma of the uterine body (after Orth) . . 247 Fra. 47.—Epithelioma of the cervix (after Orth)... . . - 248 INTRODUCTION. I po not think any student of the history of medi- cine will for a moment dispute the assertion that the importance of the changes wrought in our surgical technique within the past ten years is unparalleled by that of any previous century of medical or surgical progress. Those changes which were inaugurated with the recognition of the infectious nature of wound-inflam- mation were distinctly revolutionary, while the changes of the more immediate past have been evolutionary in character; accepting the germ theory as the work- ing principle, the object of our toilers in the field of original research has been the elaboration of a method by which these enemies to successful surgery might be eliminated from the field. This direct application of the principle in the prac- tical field has been but recently satisfactorily estab- lished after numerous experiments conducted in the laboratory upon animals and tested upon patients in the operating-room. Only by a slow process, considering the vast number of experiments conducted in all our hospitals, have we grown out of an antisepsis of toxic drugs into the xvii xviii INTRODUCTION. simpler antisepsis of moist heat and saponaceous de- tergents. Throughout these momentous changes in the surgi- eal arena Dr. Robb has been a faithful observer, and not an observer only, but frequently an active par- ticipant, assisting the evolution of the new idea, con- stantly following the work of others, repeating their experiments, and performing experiments of his own, notably in connection with my own work, which have been valuable in aiding the progress of the technique step by step until it has attained its present position. It was Dr. Robb’s work in relation to disinfection by permanganate of potassium and oxalic acid which first established on a scientific basis the reliability of this method when applied to the hands. His studies regarding the infection of the drainage-tube tract are also notable. It is therefore on account of his labors in the bac- teriological laboratory, while keeping himself at the same time constantly in close relation to the eminently practical surgical questions of the day during a decade of unprecedented progress, that Dr. Robb is eminently qualified to speak and command our interested atten tion in relation to the subjects treated in the book before us. Howarp A. Ketty. ASEPTIC SURGICAL TECHNIQUE. CHAPTER L IMPORTANCE-TO THE SURGEON OF A BACTERIOLOGICAL TRAIN- ING—SEPSI8 AND WOUND-INFECTION—MICRO-ORGANISMS OON- (CERNED—ASEPSIS—ANTISEPSIB. Tue number of those who do not believe it necessary to observe stringent precautions in operative surgery or who are content to confine themselves to methods which have been proved to be faulty is now, fortu- nately, very small, and is diminishing every day, so that we may safely say that every prominent surgeon is now working on practically the same lines, being anxious to discover and to carry out any measure which promises to aid the speedy healing of the wounds which he makes and to obviate the danger of infection. Among the brilliant results to be obtained from the study of bacteriology, none seems at the present time more important than the establishment on a scientific basis of a thorough technique for surgical operations. It will obviously be impossible for a surgeon to have any fixed rules by which he may be guided unless he has first obtained a true conception of the meaning of 9 10 ASEPTIC SURGICAL TECHNIQUE. the terms sepsis, asepsis, and antisepsis, and is deter- mined at all costs to apply his knowledge practically to his every-day work. While the majority of our operators of to-day may theoretically appreciate the dangers of wound-infection, and have read or heard of the various means that are to be taken to prevent it, there are few comparatively who are consistent in the technique which they employ. It is by no means unusual to hear a surgeon remark that he has performed an “aseptic” operation, or that he always operates “under strictly aseptic precau- tions,” when his technique, as actually observed by one trained in bacteriology, is found to be wofully defective. The practical scientific application of an aseptic and antiseptic technique can be thoroughly carried out only by observing every, even the most minute, detail, the utility of which has been proved by bacteriological experiment. In order to become familiar with these details, and to be able to appreciate them fully, the surgeon should have had at least an elementary train- ing in