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polymerization of the formaldehyd is almost entirely prevented, and a
dry gas is insured and given off at the pipe (h).
The room should be left closed overnight and thoroughly aired
thereafter. The bare floor must then be scrubbed with hot water and
soda and flushed with a three-per-cent carbolic-acid solution.
As little furniture as possible should be found in an operating
room, and this preferably of undecorated enameled iron.
Instrument Cabinet.—For the instruments and dressings there
should be a dust-proof cabinet of iron and glass, such as is shown in
Fig. 4.
 Fig. 4.—Instrument Cabinet.

Operating Table.—The operating table should be of like

construction and as plain as possible. Its top can be padded with
sterilized felt, protected from moisture by rubber sheets. A surgical
chair of plain construction might suffice, inasmuch as most plastic
operations cover but a small area and are usually about the head
and often performed under local anesthesia. A chair with head rest is
much more comfortable, adding much to the moral and physical
comfort of the then conscious patient. A very desirable chair is
shown in Fig. 5.

Fig. 5.—Operating Table.

Instrument Table.—An instrument table, such as is shown in the

next illustration, is quite necessary, upon which dressings and
instruments are laid during operation. In this the frame is of white
enameled iron and the top and shelf of plate glass.
 Fig. 6.—Instrument Table.

Irrigator.—An irrigator is often of service, especially in washing

out the fine pieces of bone resulting from chiseling or drilling. In skin-
grafting it may be used with sterilized three-per-cent salt solution as
described later. The best irrigators are those of germ-proof or
ground-glass stopper type. They are suspended from the wall by
means of an iron bracket or pulley service or placed upon a movable
enameled stand as shown in Fig. 7.
Irritating antiseptic solutions are to be avoided, their especial
indication will be found under antiseptic care of wounds.

CARE OF INSTRUMENTS
All instruments should be of modern make, devoid of clefts or
grooves, and having separating locks when possible. Wooden or
ivory handles should be entirely discarded. They should first be
 rendered free of dirt or dried blood by
scrubbing briskly with a stiff nailbrush and
hot water; then dried and placed in the
sterilizer. The immersed instruments are
boiled for five or ten minutes. There are
many of such sterilizing apparatuses to
be obtained, all made on the same plan,
however, and consist of a copper or brass
box and cover well nickel plated. Folding
legs are placed beneath. A perforated
tray is placed within for the immersion of
instruments. An alcohol lamp with
asbestos wick furnishes the heat.
One per cent of carbonate of soda
added to the water prevents them from
rusting. The simple subjection of
instruments to carbolic-acid solutions or
antiseptics of like nature is useless.
(Gärtner, Kümmel, Gutch, Redard, and
Davidsohn.)
From the sterilizer the instruments are
placed in a glass tray containing a one-
per-cent lysol solution. Knives, needles,
and scissors should be immersed in a
tray with alcohol, as a great number of
antiseptics destroy their cutting edges.
Glass or porcelain trays are best for this
purpose. A sterilized towel being placed
in the bottom of each for the better
placing of instruments.

Fig. 7.—Irrigator.
After operation all instruments should
again be scrubbed with soap and hot
water, immersed a moment in boiling
water or a jet of live steam, dried with an aseptic cloth, and returned
to the case.
 A very effectual means of rendering instruments sterile is to place
them in a metal box and bake them in the ordinary oven (200° F.) for
one hour.
To preserve needles Dawbarn advises keeping them in a
saturated solution of washing soda. Albolene has an unpleasant
oiliness, but is otherwise good. Calcium chlorid in absolute alcohol is
efficacious, but expensive. All rust accumulating on instruments must
be carefully removed with fine emery cloth; this, however, is
unnecessary if the soda solution is used as previously mentioned. It
is well to occasionally dip the instruments (holding them with an
artery forceps) into boiling water as they are used during operation.

Fig. 8.—Instrument Sterilizer.

PREPARATION OF THE SURGEON AND

ASSISTANTS

Care of the Hands

The hands of the surgeon and his assistants must always be

thoroughly prepared before operation or dressing a wound. The
mere immersion of the hands into an antiseptic solution is not
sufficient to remove germ life. The oily secretions of the skin and its
folds, as well as the cleft about the nails and the nails themselves,
are common carriers of infection and are cleansed only by the
vigorous method of scrubbing with soap and water and then
rendered aseptic by the use of proper media.
The aseptic hospital washstand, as shown in Fig. 9, will be found
an ideal piece of furniture; it has a frame constructed of wrought iron,
white enameled. The top is of one-inch polished plate glass, with two
twelve-inch holes.

Fig. 9.—Aseptic Washstand.

The entire stand can be moved away from the wall, to permit of
thorough cleaning of basins, supply pipes, etc. The basins are the
best annealed glass, and are supported by nickel-plated traps, with
connections for vent pipes. The water supply is controlled by foot
valves, which enable the operator to draw either cold, medium, or
hot water at will. The waste is also controlled by a foot valve, as
shown.
The systematic law of cleansing the hands should be insisted
upon at all times. Rules for the method followed might be displayed
in abbreviated form in the operating room by glass or enameled
signs hung on the wall over the basin and reading as follows:

YOUR HANDS

I. Clean nails.
II. Scrub with very hot water and soap for five minutes.
III. Wipe in sterile towel.
IV. Brush with eighty per cent alcohol.
V. Dip into antiseptic solution.

Green soap is commonly used and is to be preferred to powdered

or cake soap. The powder cakes and clogs the container in damp
weather, while the latter collects impurities from the air. Synol soap,
also liquid, is perhaps the most ideal, a two per cent solution of
which forms an excellent lavage for cleaning instruments, as well as
washing down furniture in the operating room.
The brushes to be used are of the common wooden-back, hard-
bristle make, which can be boiled without injury. There should be
several of these, marked on their backs as desired, so that one
brush can be used for the one purpose only. In cleansing the hands,
the forearms, and even the elbows, should be similarly treated. After
scrubbing with soap, as directed, they are to be rinsed, dried with a
sterilized towel, again scrubbed with alcohol, and then dipped or
flushed with a bichlorid solution.

Gowns

No woolen garments should be allowed to come in contact with

the site of the operation, nor is it well to allow such material in the
operating room while working.
Freshly laundered linen gowns of Von Bergman’s pattern, reaching
to the shoes, should be worn. They should contain half sleeves and
be buttoned on the back. See Fig. 10. These may be sterilized in the
steam sterilizer or washed in one-per-cent soda solution. When
soiled or blood-stained they should be relaundered.
The operator may substitute the gown with a rubber apron of the
Triffe pattern, reaching as high as the collar, but continuous washing
quickly ruins them. See Fig. 11.
Fig. 10.—Von Bergman Operating
Gown.
 Fig. 11.—Triffe Rubber Apron.

PREPARING THE PATIENT

General Preparation

The patient for all plastic operations should be carefully examined

as to general health and past history. His healing powers should be
at their best, as much depends on primary union. If he presents a
syphilitic history, it is well to place him under treatment, for a time, at
least, before an operation is undertaken. The bowels should be
regular. Sulphate of magnesium should be given each morning,
before breakfast, for at least two days prior to operating, while his
general condition may be improved by the employment of bitter and
alterative tonics. Nux vomica with tinct. cinchonæ com., associated
with essence of pepsin aromat., or lactopeptone, are very useful.
This treatment is also carried on for several days, post operatio.
The success of an operation depends, first, upon the selection of
the case; second, the selection of the method employed, and, third,
upon the hygiene under which the patient undergoes convalescence.
The patient must be given to understand, in many cases, that it is
often necessary to reoperate, even to the extent of seven or eight
operations, to bring about the desired result. The first result obtained
with many cosmetic operations is not at all gratifying to the patient,
and unless this is explained to him beforehand he may become
discouraged awaiting the next operation and disappear, thus losing
the opportunity of being pleased finally, while the surgeon is
misunderstood and underestimated by narrow-minded judges and
the ever-willing friendly advisers and critics—a consummation much
to be avoided.

Preparation of the Operative Field

The part to be operated upon should first be closely shaven. The

oily secretions of the area are next rubbed off with an absorbent
cotton sponge saturated with alcohol or ether. Next, the skin is
washed with hot water and soap or three-per-cent synol suds, then
rinsed, and finally rendered aseptic with a bichlorid solution.
If the operation is to be done about the face a rubber cap is so
adjusted as to cover the hair. If this is not obtainable sterilized
bandages can be employed.
In operations about mucous membranes, as in the nose and
mouth, the parts must be cleaned at short intervals with a solution of
permanganate of potash or boric acid. The teeth must be cleansed
with antiseptic soap, tartar is scraped off, and the mouth rinsed with
a proper disinfectant. The corrosive sublimate, or carbolated
solutions, owing to their toxic qualities, cannot be used. The
preparation of wounds for reoperation, or where an operation is
secondary to injury, is referred to later.
All clothing about the site of operation should be removed and
rubber cloth placed to surround the field and cover the clothing. This
should be covered again with sterilized towels. Everything that
touches the patient after this has been done should be aseptic;
indeed, hands employed during operation must be immersed from
time to time in 1-500 bichlorid solution, and allowed to remain wet.
 CHAPTER III
REQUIREMENTS DURING OPERATION

SPONGES AND SPONGING

Natural or sea sponges are now little used in surgery, owing to
their peculiar cellular construction. They invite and readily retain
spores and germs, are difficult to clean, and require almost constant
attention to be at all safe.
Many methods for rendering these sponges aseptic have been
proposed, but at best the life of such a sponge is short and hardly
pays for the labor and time expended. The absorbing power of a
sponge is, of course, its essential quality. For plastic operations
sterilized absorbent cotton made into small balls answers every
purpose. These puffs of cotton are covered with gauze to prevent the
fraying out of the fibers. To further improve them, their centers may
be made up of cellulose or wood fiber. When an absorbent cotton
sponge is moistened and squeezed out it does not answer as well,
since its absorbing qualities are much reduced; the addition of the
other material overcomes this.
A much-used and inexpensive sponge having great absorbing
power is made in the form of a small compress of sterilized gauze
held together with one or two stitches of thread. All of the above
sponges are sterilized with the needed dressings and are burned
after use. When removed from the sterilizer they are placed in a
suitable basin containing six per cent sterilized salt water. It is well to
place the receptacle close by the assistant who is to sponge. An
enameled iron basin rack, as shown in Fig. 12, answers the purpose
best.
 Fig. 12.—Basins and Rack.

The soiled sponges are thrown into a lower empty basin or one
placed at the operator’s feet. As they are removed from the solution
they are squeezed as dry as possible and pressed upon, rather than
wiped across, the operative field. It must be remembered that the
surgeon’s work must not be hampered by slow or inefficient
sponging, and that this procedure must be quick and timely. It is well
for the assistant to become accustomed to the habit of the operator.
The best assistant is one who has acquired a methodical and
regular manipulation, a result dependent upon constant individual
association; such a one is practically invaluable for the skillful
performance of plastic surgery. He becomes not only familiar with
the one thing, but cultivates a ready knowledge of the arrest of
hemorrhage by digital compression when hemostatic forceps would
hinder the ease of work, besides cultivating a happy manner of
holding retractors or spreading the edges of the incisions with the
free hand. As in most of these operations hemorrhage cannot be
controlled by the so-called bloodless method. The assistant must
control the constant oozing by the gentle pressure of the sponge
quickly applied at short intervals. When the sponges are squeezed
out in salt solution, as hot as the hand will bear comfortably, capillary
oozing is more readily overcome.

STERILIZATION OF DRESSINGS
All dressings to be used in covering wounds, post operatio, or
otherwise, must be as scrupulously clean and free from infection as
the hands and the instruments of the operator. This is done by
means of sterilization by dry heat or steam under pressure. For all
minor cases, small apparatuses only are needed. They are usually
made of copper, often nickel-plated, and so constructed as to contain
a lower perforated instrument tray and another, placed above it, for
dressings. The two are fitted into an outer copper receptacle with
snugly fitting cover. A folding stand is furnished upon which this
arrangement is placed, and an alcohol lamp with asbestos wick
furnishes the heating power. The lower tray is covered with water
which, by boiling, fills the upper compartment with steam evenly
distributed and with sufficient pressure to accomplish sterilization in
from thirty to sixty minutes. Metal hooks are provided with which the
trays can be removed. A complete and compact outfit, as designed
by Willy Meyer, is shown in Fig. 13.
In the above sterilizer, or in those of similar type, there is naturally
more or less saturation of the dressings and the possibility, in the
event of the entire conversion of the water contained therein into
steam, of injuring the instruments by excessive heat. To overcome
this defect the Wallace sterilizer may be advantageously employed.
 Fig. 13.—Willy Meyer Sterilizer.

Fig. 14.—Wallace Sterilizer.

Wallace Sterilizer.—Its chief feature is the addition of a reservoir

fitting with the separated sterilizer into the outer body. See Fig. 14.
This reservoir automatically regulates the water and steam supply. It
is filled with water and inserted into the compartment provided for
and adjoining the sterilizer. Through an opening in the bottom the
water is permitted to escape into the sterilizer until the bottom of the
latter is covered to a depth of ⅛ inch. As the heat is applied from the
alcohol lamp this film of water is rapidly converted into steam.
The dressings arranged in the large tray are placed in the sterilizer
and the supply of steam is maintained through the constant and
steady flow of water from the reservoir, which compensates the
evaporation in the sterilizer. In about twenty minutes the formation of
steam in the top of the reservoir exerts sufficient pressure to force all
the boiling water from the reservoir into the sterilizer to the depth of
about 1½ inches. The tray of instruments is now inserted and the
process continued for another ten minutes. Much less heat is
required with this apparatus than with those of ordinary type, while
sterilization can be continued uninterruptedly for one and one half
hours, if need be.
Sprague Sterilizer.—The most perfect sterilizer is that of the
Sprague type, in which a dry chamber is surrounded by steam under
pressure. The apparatus is shown in Fig. 15.
 Fig. 15.—Sprague Type of
Sterilizer.

Its cylindrical chamber is surrounded by two heavy copper shells,

the space between which is occupied by the water. This
compartment is entirely shut off from the sterilizing chamber, and as
the steam is generated, the inner, or sterilizing, chamber becomes
heated to a degree nearly equal to that of the steam in the
surrounding cylinder; this prevents any condensation of steam taking
place in the dressings. By opening the lever-handled valve at the
bottom of the sterilizer in the rear, and the valve to the right, on top of
the sterilizer, and allowing them to remain open for a space of four or
five minutes, a vacuum is formed in the sterilizing chamber. These
two valves are then closed, the lower one first, and the steam from
the outer cylinder is allowed to enter the chamber, by opening the left
valve on top.
The contents should be allowed to sterilize for twenty or twenty-
five minutes under a pressure of fifteen pounds. Then close the
steam-supply valve; open the vacuum valve (right) and the lever-
handled valve at the bottom; leave these open about the same time
as in creating a vacuum at the beginning of the process; close both
valves, then open the air-filter valve on the door, in order to break the
vacuum; the door can then be opened and the dressings be taken
out dry and absolutely sterile.
The steam-safety valve on this sterilizer is set at seventeen
pounds, but it can easily be regulated should a higher or lower
pressure be desired. The door used on this apparatus has no
packing of rubber or other soft material which wears or shrinks in
time, a steam-tight joint being formed by the bringing together of two
plane metal faces on the door and sterilizer head. The door hinge is
so made that these parts are bound to come together properly,
without the use of excessive caution. Springs on such doors are
liable to get out of order or need replacing, and are avoided in this
apparatus. All that is necessary to lock or unlock the door is to turn
the large hand wheel on the front; the locking levers then work
automatically. These sterilizers are arranged for both gas and steam
heat.
Sterilizing Plant.—For the ideal operating room the entire
sterilizing plant can be had in combined form, as shown in Fig. 16. It
consists of a dry-heat dressing apparatus, just described, water and
instrument sterilizers, all mounted on a white enameled, tubular,
wrought-iron frame. The chamber of the dressing sterilizer is 8½ by
19 inches. The water sterilizer has a capacity of six gallons in each
tank and is fitted with natural stone filters, thermometer, water
gauge, safety valve, etc. The size of the instrument sterilizer is 8 by
15 inches and 6 inches deep, with two trays. Each apparatus in the
above can be used independently of the other, all being arranged for
gas-heating.
 Fig. 16.—Sterilizing Plant.

Dressing Cases.—All dressings should be sterilized immediately

before operation, and not laid away for later use, as often done. As
the aseptic material is taken from the sterilizer it is to be placed in
glass cases provided therefor, from which they are removed, as
needed, during the operation.
A simple glass case, as shown in Fig. 17, may be used, or, better
still, the same can be obtained in combination with an instrument
table, as shown in Fig. 18.