CHAPTER XIV. Operations in the country, in private houses, or in other (Part 1)

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 ...... CHAPTER XV. Anesthesia as an aid to diagnosis: its importance in general surgery and gynecology—Preparation of the patient— Position—Methods of examination—Rectal palpation . . CHAPTER XVI. Bacteriological and clinical examinations in surgery and gynecology ...... Sadi Webs Seas CHAPTER XVII. The examination of the interior of the female bladder, and the catheterization of the ureters .........-. CHAPTER XVIII. Pathological examinations ....,.....2+.-- CHAPTER XIX. Endometritis : Nomenclature—Histology—Changes in endo- metrium during menstruation and in old age—The De- cidua—Infections— Gonorrhea—Septic endometritis— Trophic endometritis ......... a6 PAGE 196-208 209-217 218-227 (228-237 238-252 252-279 LIST OF ILLUSTRATIONS. PLATES. Puarez I.—Figures of eight different bacteria . . . Frontispiece Pratz Il.—Sterilization of the hands with permanganate of jE © Sigs eo ods toes eked eee 6 Prate III.—Fig. 1, Long dressing-forceps; Fig. 2, Drainage- tube forceps with Kelly’s lock... 1... ......-- Pirate I1V.—Fig. 1, Hemostatic forceps ; Fig. 2, Bullet-forceps . Prats V.—Fig. 1, Rat-tooth forceps; Fig. 2, Curved needles; Fig. 8, Transfixion needles... ......+-:0.4- Prare VI.—Fig. 1, Needle-holder; Fig. 2, Vaginal packer; Fig. 8, Retractor; Fig. 4,Scalpels. . 2... ....... Priate VII.—Fig. 1, Scissors; Fig. 2, Uterine sound; Fig. 3, SNS GEICN OT. Gs 6 oe 8B coe 5 Gee eee Puatz VIII.—Fig. 1, Trivalve speculum; Fig. 2, Sponge- holder; Fig. 8, Corrugated tenaculum .... 2... 6 Prare IX.—Fig. 1, Trocar; Fig. 2, Nélaton’s forceps Puate X.—Fig. 1, Simon’s speculum ; Fig. 2, Curettes . Prate XI.—Fig. 1, Modified Goodell-Ellinger dilator, smallest size; Fig. 2, Hegar’s dilator; Fig. 8, Shot-compressor. . . Piatz XII.—Fig. 1, Two-way catheter; Fig. 2, Chloroform- bottle; Fig. 8, Chloroform-inhaler; Fig. 4, Tenacula .. . Puate XIII.—Fig. 1, Glass dishes; Fig. 2, Sterilized towels in three-per-cent. carbolic solution; Fig. 3, 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 gauze in glass jar; Fig. 7, Ligatures in glass jar; Fig. ep CAUZECISINSMGE Ns (eis aie Sele his © Gis a = 5 < Puare XIV.—Fig. 1, Flasks for sterile salt solntion; Fig. 2, MED METS 5 WG 6 5 oO oe) Bio e onOgee PAGE val 7 7 72 74 75 76 78 78 86 xiv LIST OF ILLUSTRATIONS. Piatz XV.—Gynecological operating-room, Lakeside Hospital, Cleveland) Ohi, <7) <4) ee een Piate XVII.—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. 5, Agate-ware vessel, with top protected with gauze... 2... ......-: Piare XVIII.—Field of operation and the neighboring parts protected by gauze diaphragm, towels, and stockings. . . . Puate XIX.—Examination under sheet... .......- Pirate XX.—Patient in knee-chest position, cystoscope about to be inserted (after Kelly)... .....-..++4¢; Priate XXI.—Fig. 1, Normal mucous membrane of the uterus (after Zweifel); Fig. 2, Chronic interstitial endometritis (after Zweifel) 2. 2). ss Puate XXII.—Fig. 1, A normal cervical gland; Fig. 2, Nortal senile aistaneeton Bee eo eo a 5 Prarz XXIII.—Fig. 1, Interstitial exudative endomteniaet Fig. 2, Hypertrophy of uterine glands. ........ . PLATE XXIV.—Tuberculons endometritis .......+. ae FIGURES. Fig. 1.—Hotair sterilizer... 2... ee ee ee Fic. 2.—Hot and cold watertanks...........-. Fig. 3.—Steam\sterilizer 2. . 1... 6. 2. « 2) s Oe Fig. 4.—Steam sterilizer (in section). ........... Fie. 6.—Suits worn by operator and nurse ....... . Fie. 6.—Spigot attachment ....... Cee as 6 mS Fira. 7.—Robb’s aseptic razor, with case... . . 2 =) Seis Fic. 8 —Instruments in metal box ........-..-.-- Fie. 9.—Boiler for soda solution... ..... Pee a Fie. 10.—Instrument sterilizer... 5. 11.1 ee ee es Figs. 11, 12.—Basins for instruments... . . CRORE) © GG Fic. 13.—Aseptic ligature tray ......... - > 6 Fie. 14.—Needle armed with carrier. .......... . Fig. 15.—Glass reels for ligatures . 2... . 2... 1s O56 Fis. 16, 17.—Ignition test-tubes with ligatures on reels. . . . Fic. 18.—Sterilized catgut in sealed glass tubes. . . . . se PAGE 154 176 214 232 242 254 260 270 35 36 387 38 49 62 81 85 88 89 92 94 94 96 LIST OF ILLUSTRATIONS. xV PAGE Fig. 184.—Tube of sterilized catgut. ....... Ga aec JS Fie. 19.—Modified Scultetus bandage .....-... cho inet Fia. 20.—Sponge made of cotton and gauze .... 112 Fig. 21.—Thermometer jar 132 Fia. 22 —Glass douche-nozzle ..... Romo atone a 184 Fia. 23.—Aseptic powder flask ......+++...- ae HES ich 24.-Glnssicatheter . . . . ss 3 ss oe he et 145 Fic, 25.—Glass catheters in one to twenty carbolic acid solution . 146 Fig. 26.—Movable incandescent lamp. ...........- 150 Fia. 27.—Operating-table: Robb’s electric light attachment . . 151 ¥Fia. 28 —Halsted’s semicircular table for instruments. . . . . 154 Fria. 29.—Rubber ovariotomy pad... .......-2-- 164 Fia. 80.—Sponging out cul-de-sac. . 2... 2.22 ewe 171 Fia. 31.—Removal of abdominal sutures .......... 176 Fias. 32, 83.—Robb’s leg-holder ........--.... 176 Fig. 84.—Hot-watercan... 2... Goo G0 bes 6 oon 179 Fig. 85.—Abdominal bandage .. .........-4.. 191 Fie. 36.—Canton-flannel sheet for instruments ........ 198 Fig. 37.—Instruments wrapped in canton-flannel sheet . . . . 199 Fie, 38.—Double urethral dilator... 2... 2... ee we 230 Fic. 89.—Speculum and obturator . 2... ......0.-4 230 Fig. 40.—Delicate mouse-toothed forceps .......... 22 Fig. 41.—Ureteral catheters, without handles, for direct catheter- ization through speculum, ..-...........5- 231 Fic. 42.—Section through a blood-clot from the uterus after abor- tion, showing transverse and longitudinal sections of chori- rie willit(atten Orth) ye. cee ns ke 6 ee es 246 Fia. 43.—Adeno-carcinoma of the uterine body (after Orth) . . 247 Fig. 44.—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- cal 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. 7 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. Kety. ASEPTIC SURGICAL TECHNIQUE. CHAPTERI IMPORTANCE TO THE SURGEON OF A BACTERIOLOGICAL TRAIN- ING—SEPSIS AND WOUND-INFECTION—MICRO-ORGANISMS CON- CERNED—ASEPSIS—ANTISEPSIS. 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 dangers 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 bacteriology. If he has not had this training, —and, unfortunately, it has not as yet been possible to secure it at the majority of medical schools,— he must accept and carry out in his work princi- ples which have been laid down by those who have had the opportunity of submitting their methods to the test of bacteriological criticism. Any one who has been trained in a bacteriological laboratory will have exalted ideas of surgical cleanliness, and cannot INCONSISTENCIES IN TECHNIQUE. ll fail to see the many inconsistencies that occur dur- ing the majority of operations. While these incon- sistencies may to many appear trifling, in reality they are only too often responsible for the introduction of infectious material into the wound. One would think that an operator, after taking every precaution to render his hands surgically clean, would avoid bringing them in contact subsequently with objects which have not been previously sterilized, and yet it is by no means uncommon to see those who are re- garded as “careful men” touching with their hands the face or hair, or permitting them to come in contact with some non-sterile article—such, for example, as a blanket which protects the patient—just prior to or during an operation, and proceeding with their work without thoroughly cleansing them again. If such errors in technique be committed by the operator him- self, he can scarcely expect his assistants and nurses to exercise proper precautions. I remember seeing a surgeon leave the operating- table, while performing an abdominal section, to pick up an unsterilized instrument which he wished to bend at a certain angle and employ in order better to expose the parts. In doing this he used as a support a table and a chair that happened to be near at hand, but which were unsterilized. After having bent the instrument to the desired shape, the surgeon proceeded to employ it immediately without making any attempt to sterilize either it or his hands. I have also seen a nurse, who was assisting with the handling of the 12 ASEPTIC SURGICAL TECHNIQUE. sponges at an abdominal section, take her hand- kerchief from her pocket, wipe her nose with it, and at once continue with her duty of passing the sponges to the assistant surgeon. On another occasion I saw a surgeon open an abdomen, and after himself exam- ining the structures of the pelvic cavity, invite two professional brethren who were looking on to do the same; and they were actually permitted to introduce their hands into the wound after having simply washed them for a minute or two with soap and water in a soiled basin. At another time an assistant, after draw- ing a ligature between his teeth, proceeded to thread the needle with it for the surgeon to use in the abdomi- nal wound. Some surgeons have even been guilty of holding the scalpel between the teeth in the course of an operation. It would hardly be necessary to mention such glaring instances of faulty technique were it not for the fact that errors as bad as these have been observed in men who are considered leaders, and to whose lot it falls to instruct others in surgery. While the surgical judgment and skill of such men may be undoubted, the technique which they employ is dangerous and per- nicious. Even after we have become thoroughly im- bued with the importance of aseptic work, and have made the most careful preparations before our oper- ations, the technique will never be perfect unless we have schooled ourselves to provide against the unfore- seen dangers which are constantly turning up in the operating-room. Every operator of experience, no INFECTION. 138 matter how conscientious and careful, has met with fatal cases in his practice due to faulty methods, and has had inflammation with pus-formation at or near the site of the wound which he has made. He who is thoroughly conversant with the condi- tions which underlie suppuration in wounds and septic processes generally, knows only too well how many are the loop-holes for infection, and to him it seems really remarkable that such cases do not occur more frequently. It is not improbable, especially in condi- tions of lowered resistance where the cells and tissue fluids of the body do not exercise their normal germi- cidal power, or do so only in a feeble way, that infec- tion may occur, even though all possible precautions have been taken by the surgeon and his assistants. Experiments have shown that no method has yet been discovered by which the skin can be rendered abso- lutely sterile, and that the cutaneous glands contain, even after the most careful disinfection of the surface, micro-organisms which in a proper “soil” are capa- ble of giving rise to inflammation and suppuration. Though it may be true, as has been contended by good men, that every wound made by the surgeon contains micro-organisms, we may assume that under ordinary circumstances the resisting powers of the patient will be sufficient to prevent their growth and _ development. Experience, however, has taught us that there are several kinds of bacteria which under certain conditions possess such virulence, that when introduced into the tissues even of a perfectly healthy 14 ASEPTIC SURGICAL TECHNIQUE. individual they are capable of setting up violent local or general infections. And it is only right that every surgeon shall do everything in his power to prevent the ingress of such bacteria. While admit- ting that an infection following an operation must, with our present knowledge, be sometimes attributed to a lowered systemic resistance and to no fault on the part of the operator or his assistants, it must be understood that this is a very rare occurrence, and that in nearly every septic case a rigid analysis of the technique employed will bring to light some sin of omission or of commission to account for it. I believe that a perfect technique can ultimately be attained by submitting every step to the test of bac- teriological examination, and the surgeon who works on these lines will, ceteris paribus, undoubtedly obtain the best results in his own operations, and, what is perhaps just as important, he will be able by his teach- ing and example to inculcate in others principles by the adoption of which much loss of life may be pre- vented. That some surgeons do not seem to pay much at- tention to a careful technique and yet obtain good results is no sound argument against the carrying out of thoroughly scientific procedures. As a matter of fact, a careful investigation of their results and those of their followers compared with those of aseptic surgeons and their students will, if a suffi- cient number of parallel cases be taken, certainly show the inferiority of the older methods. Statistics SEPSIS. 15 showing uniformly good results from operations in which no precautions were taken will usually be found to be based on too limited a number of cases to be of much value. The term sepsis, or septic infection, includes nearly all of the surgical infections, general or local, result- ing from bacterial invasion. The symptoms are due, as a rule, not so much to the direct effect of the bac- teria themselves as to the action of their chemical products. When the bacteria have gained entrance into the general circulation and have multiplied there (and several varieties are capable of doing this), we have a general blood-infection which often proves fatal. With or without extensive multiplication of the micro-organisms in the blood, the system may be overwhelmed with the bacterial poisons. This condi- tion is called acute septicemia. Localization of pyo- genic bacteria in the organs, especially when they have been transported there by infectious emboli, gives rise to multiple abscess-formation. This condi- tion is called pyemia. These terms are, of course, only relative, and it