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require but slight suturing, and with fine catgut which will loosen of
itself within two or three days; the intent in such cases always being
to assist the sutures by proper support of the external dressings.
Buried sutures will serve a useful purpose in many instances, and
upon the face or exposed parts of the body a subcutaneous suture of
fine silk or horse-hair may be so applied as to be easily removed by
a single pull and leave but trifling disfigurement. Female patients will
be doubly grateful if the surgeon can leave but a minimum of
unsightly scar. Fasciæ will sometimes retract widely. They should be
brought together by distinct separate catgut sutures. Before closure
of a wound it is important to determine that no such structures as
nerves or tendons have been divided, or, if such injuries have
occurred, to reunite their ends by fine silk or catgut sutures. The
writer prefers silk for most of these purposes, although in a nerve a
fine formalin catgut suture would perhaps be the most ideal.
There are occasions when it seems impossible with the means at
hand to tie or secure in any way a deep bleeding vessel which has
already been seized with a hemostat. In such case the forceps may
be left in situ for thirty-six to forty-eight hours. This may be done, for
instance, in the groin, in the axilla, in the depths of the neck, and
about the cranial sinuses. Life may be occasionally saved by this
procedure which would be lost from hemorrhage without it. At other
times a firm tampon of gauze may be forced into the depths of a
wound for the same purpose, and maintained there by position, or by
the pressure of secondary sutures, which serve the same purpose
and require removal in two or three days. These measures refer
rather to wounds of veins than of arteries.
If one can be absolutely sure of his asepsis, he may close even an
extensive wound with little or no provision for drainage; but unless he
is certain regarding it he should provide at least for escape of fluid by
omitting a suture occasionally, or by drainage with a tube or a
cigarette drain. In compound fractures not only must such provision
be made, but the treatment of the wound may also include the
introduction of wire sutures through bone ends or the use of other
mechanical expedients.
The further and equally important treatment of wounds consists
largely in maintaining physiological rest of the injured part, as well as
the general welfare of the patient. Pain which becomes unendurable
causes the patient to lose self-control and to disturb not only the
dressings but apposition of wound surfaces. Pain, therefore, should
be controlled by the mildest expedient that may suffice to master it.
Elimination must be maintained, because the circumstances
attending the injury may act to disturb it. A patient who shows no
irregularity of pulse, temperature, elimination, or general comfort
may be assumed to be doing as well as could be expected, and the
dressings need not perhaps be changed for several days. On the
other hand, with rise of temperature or pulse, increase of
restlessness, swelling of the parts, or discomfort in the vicinity of the
wound, the dressings should be promptly changed. It may be
necessary to make such change at the end of forty-eight hours in
order to permit the removal of the drain. The second dressing may
then often remain a week, but any dressing which becomes
saturated, even with blood, may dry and adhere to the skin, and
should be removed.
It would be best to inspect the wound in all cases when the
temperature and pulse are rising or when there is any disturbance in
the wound. The accumulation of blood in an aseptic wound may
cause much discomfort, and by its presence interfere with primary
union. Should, therefore, a wound be found pouting or its edges
reddened and swollen it may be safely assumed that there is
something wrong, and as many sutures should be removed as may
be necessary to reveal its condition and permit of its treatment.
Wounds which are foul or septic when they come under surgical
observation should be treated differently. Here the first attempt
should be at antisepsis. In some cases continuous immersion in
warm water will give the best results. I have never found anything so
prompt, however, in cleaning up a sloughing area as brewers’ yeast.
When this can be obtained it should be used in sufficient abundance
to get the diseased surface thoroughly wet with it. In sloughing cases
moist dressings are usually preferable, and the best are the two
above mentioned. This is true of those cases where part of the
wound is granulating satisfactorily, while part is acting badly.
Dressings in all of these cases require to be frequently changed, that
they may be kept effective.
 I have elsewhere called attention to the value of granulated sugar
as an emergency antiseptic material of great value.

SUTURES AND KNOTS.

Sutures.—There are many varieties of sutures which have found
favor. Until the surgeon becomes expert by long practice
he should confine himself to few sutures and knots. Primary sutures
include continuous, interrupted, plate or modified plate, quill or
modified quill, chain, and transfixion sutures, and also certain forms
of suture used in intestinal surgery. The above forms are illustrated
in Figs. 61 to 66. Several of them may be used in making what are
known as buried sutures, i. e., those which are tied deeply, whose
ends are cut off below the surface and left either permanently or for
later absorption.
The purpose of a suture is to bring the parts into accurate
apposition and so maintain them. It is a mistake to employ a
superficial suture alone, which may leave a “dead space” beneath it.
If but one suture is used, as in closing an abdominal wound, it should
pass through the tissue layers of the abdomen and bring each layer
into contact with the corresponding layer on the other side. Unless
this can be done a series of sutures should be used uniting the
tissues layer by layer. If these be made of formalin or chromic gut
they will remain in situ for a length of time sufficient to serve their
purpose. Some prefer silk for this purpose, but it may work out later;
if sterile and freshly boiled just before using it will rarely cause this
trouble. In closing a thick and fat abdominal wall four or five tiers of
buried sutures may be used and their effect may be reinforced by the
addition of a modified plate or quill suture, as shown in Figs. 63 and
64.
Fine wire is preferred by some operators, and horse-hair by
others. Success pertains rather to the perfection of the method than
to the material used. The primary feature of all wound sutures should
be prevention of tension and protection against it. Further support in
the same direction can be made by the use of adhesive plaster after
fastening the dressing upon the wound, thus taking off strain.
 Certain expedients have been resorted to in superficial wounds,
some of which include the affixion of a strip of plaster on either side
of the wound and then the application of the suture material through
the plaster rather than through the skin. Plasters with small hooks
have also been applied, and then a shoelace suture applied over the
hooks, thus lacing the wound margins together. Such measures are
convenient for certain cases, although they make the maintenance of
strict asepsis difficult or impossible. Fine-wire clips have also been
introduced, by which skin margins may be held together for three or
four days, or until they have had time to unite with some firmness,
after which they may be removed. These little implements can be
sterilized and repeatedly used.

Fig. 61 Fig. 62 Fig. 63

Continuous suture. Interrupted suture. Modified plate suture,

using gauze instead.
 Fig. 64 Fig. 65 Fig. 66

Modified quill suture, using Billroth’s chain-stitch. Transfixion suture.

gauze.

Fig. 67 Fig. 68

Reef knot. Granny knot.

 Fig. 69 Fig. 70 Fig. 71

Clove hitch.
Staffordshire knot.

When an absorbable suture will serve the purpose it is desirable to

use it, since the necessity of subsequent removal is thereby avoided.
Inasmuch as every point through which a suture is passed will show
its own minute scar, it is desirable for cosmetic purposes to use a
subcutaneous suture, which may be made of chromic gut, silk, or
fine wire. If of catgut it may be left to disappear spontaneously; but a
silk or wire suture should be left with ends protruding from the wound
so that after a few days it may be withdrawn by steady traction in the
proper direction.
Secondary sutures are those which are placed at the time of the
operation, but either not drawn so as to unite the wound edges, or
are tied with a bow-knot, so that they may be untied and utilized
later. They are useful when either hemorrhage or suppuration is
anticipated, and when it is compulsory to pack a cavity with gauze.
Every suture which has failed of its purpose or ceased to be
effective should be removed. Ordinarily they are left in place from
four to ten days. They should be removed by dividing upon one side
of the knot, which should be seized with forceps and pulled upward
and to the other side. The suture should be cut at a point where it is
moist, so that only its flexible portion may be drawn through the parts
which it has held. Moreover the buried portion is more likely to be
sterile. Secondary sutures are usually made of silkworm-gut,
celluloid thread, or wire. So soon as they are found unserviceable
they also should be removed.
Knots.—The purpose of a knot is not achieved if it slips, and the
“surgeon’s knot” is best for the purpose, since in the first
formation one end is carried twice around the other before being tied
in the opposite direction. It requires more force in making it taut, but
it is safer than the ordinary reef knot (Fig. 67).
Figs. 69 and 70 illustrate the clove-hitch, which becomes firmer
the tighter it is pulled. It is rarely used in ordinary sutures or ligatures,
but may be made exceedingly valuable. The Staffordshire knot (Fig.
71) serves especially for securing pedicles, which are first transfixed
with a double thread, the loop thus formed being slipped over the
stump and secured between the two loose ends of the ligature, one
end being placed over and the other under it; each is pulled tightly
and secured by an ordinary knot. When properly applied it is
effective. When knots are improperly applied none of them should be
trusted.
When wire sutures are used it is sufficient to twist the ends, unless
very fine wire is used, when it may be tied.
 C H A P T E R X X I V.
ASEPSIS AND ANTISEPSIS; TREATMENT OF
WOUNDS.
The medical student of the present generation has no conception
of the contrast between the results of today and those of a
generation ago, or before the introduction of antiseptic technique and
its later perfection, asepsis. Under the term “antiseptic” should be
included those measures intended to combat sepsis, or surgical
infection, from without. The term asepsis is of later date, and was
introduced when it was found that the prevention of infection was
better than measures calculated to overcome it, or atone for its
presence. A perusal of former surgical horrors will afford but an
insufficient comparison as to the incalculable benefits for which we
are indebted to a small group of men, of whom Lister is the most
important; although the names of Pasteur and of Ogston should ever
be held memorable in this connection. The two great nineteenth
century achievements in surgery were anesthesia and antisepsis,
both of Anglo-Saxon origin, one American, the other British.
It was the recognition of the parasitic, i. e., the germ nature of
surgical infections, which led to Lister’s first attempts to exclude and
combat the infecting agents. And while the original technique which
he introduced has been changed in nearly every particular, the
correctness of the views upon which it was based has been ever
broadened and strengthened. We have learned that simple
measures may be as effective as those more complicated, and the
principal changes which have been made in three decades have
tended toward simplicity and prevention. Thus heat has been made
to take the place formerly occupied by carbolic acid. And we have
learned that parts made clean need little antiseptic protection. We
have learned that healthy tissues are endowed with large powers of
self-protection, and also that this self-protection is interfered with by
causes over which the surgeon has sometimes but little control. A
wound in a body loaded with toxic products is by no means protected
against infectious agents by mere external agencies. The
appearance of pus in a wound is a reflection upon the surgeon. The
ideal aseptic technique will include many days of local and
constitutional protection, as has been stated in the sections on Auto-
intoxication and on the Preparation of the Patient.
The methods of either antiseptic or aseptic technique include as a
fundamental basis the necessity for perfect sterilization of everything
which may come in contact with the wound, so far as the surgeon
can control it. The atmosphere contains in suspension bacteria, but
their contact is no longer dreaded, because of reliance upon the
germicidal powers of the fluids and tissues of the body. It is known,
however, that in accumulation of fluids there is danger as well to the
tissues, either from rude handling, application of large pressure
forceps, the insertion of too many stitches, or whatever else may
lacerate or impair the circulation.
There are parts of the body where no precautions can afford
complete freedom from germ activity, as in the mouth, the vagina,
the rectum. Here the surgeon must be cleanly in his work, assuring
himself that he introduces nothing new from without. Furthermore,
after operation upon these parts he must ensure his precautions by
the use of mouth-washes, douches, etc. On the other hand, ample
opportunity should be afforded for sterilization of the field of
operation, of the hands of the operator and his assistants, the
instruments, ligatures, and dressings—everything which may come
in contact with the raw surface.
Heat, moist or dry, is the simplest of all sterilizing methods. It is
used in dry and in moist form. The most resistant spores are those of
anthrax, which is supposed to be a laboratory germ, one not seen in
practice. Most of the imported catgut is made from the intestines of
sheep, and sheep die frequently (on the Continent) of anthrax; it will
thus be seen that the danger of an anthrax infection is not so remote
as might first appear, and that no precautions are sufficient which do
not include a degree of heat and length of exposure sufficient to kill
these germs. In the operating-room, as in the laboratory, has been
introduced the method of “fractional,” i. e., repeated sterilization.
Most of the materials thus exposed may be left in superheated
steam under pressure from thirty to sixty minutes. They are then
exposed once or twice more to the same heat at intervals of twenty-
four hours. In order to make heat thoroughly useful its effects should
permeate everything which it is expected to so sterilize; hence the
addition of steam under pressure, especially when dressings, towels,
etc., are folded. It is well to have a form of sterilizer that permits
steam to be turned off and drying to be accomplished slowly by the
aid of dry heat.
Next to steam thus utilized is boiling water, in which nearly
everything can be sterilized. Silk sutures and silkworm-gut may also
be sterilized in this way; animal suture does not permit of it unless
previously hardened. The effectiveness of boiling water is increased
by adding to it 1 per cent. of sodium bicarbonate, by which its boiling
point is raised.
Dry heat is employed in an oven, or its equivalent, preferably in
some apparatus by which temperature can not only be measured but
maintained. In such a mechanism it is well to have the temperature
raised to 300° F. for at least half an hour, and then let its contents
cool slowly.
Another method of sterilization is by using volatile or easily
volatilized chemicals, such as formalin in its fluid form, or its
equivalent called paraform, which comes in crystals or may be had in
tablets ready for use. Formalin is a powerful bactericidal agent, and if
used in such form as to be sure of its penetration, good results may
be expected. Some materials and instruments which are injured by
steam or dry heat may be kept in an atmosphere of paraform, or
sterilized by exposure to formalin vapor, being then subsequently
protected against exposure in a sealed package. Catheters which
have been boiled or cleansed can be thus exposed, as Hutchings
has shown, and can be regarded as safe for use. They can,
moreover, be resterilized in the same way. Naphthalene has similar
properties, but is not quite so strong. The writer is accustomed to
use one or the other of these in jars or receptacles containing dry
dressings, catheters, and rubber gloves.
If aseptic methods are practised there will be but little use for the
employment of any antiseptic, either in solution or in any other form.
Boiled water and sterile salt solution should be available for all
purposes. It is customary, however, to have a solution of mercuric
chloride on hand, which is colored in order that it may not be
mistaken for any other, in which to rinse the hands, especially after
they have been in alkaline solution.
The first thing to be sterilized should be that part of the body upon
which operation is to be made. In some cases, as about the feet, the
mouth, etc., this preparation should be begun two or three days
beforehand; in other cases twelve to twenty-four hours will suffice.
Preparation should be begun with soap, nail-brush, and razor, the
parts being thoroughly cleansed and shaved. It is then customary
with most operators to keep a moist and antiseptic dressing applied
upon surfaces thus cleansed, which should be protected from drying
by a covering of oiled silk or rubber tissue. Green soap is usually
employed, which may have added to it a small percentage of
carbolic acid or lysol. The mercurial preparations are too irritating to
the skin. Carbolic acid has the reputation of being absorbed rapidly.
On tender skins and in certain parts of the body it is impossible to
make such applications, especially of soap poultices. Under these
circumstances repeated washings and some protection should be
practised. Feet upon which operations are to be made should be
soaked repeatedly and scrubbed. Twenty-four hours previously to
operating on the head the scalp should be shaved—preferably forty-
eight hours—and prepared as above. For operations in the mouth
the tooth-brush and antiseptic mouth-washes should be frequently
used. For those in the vagina, douches, etc., should be frequently
administered.
The preparation of the field of operation includes a final scrubbing,
with a washing of alcohol or alcohol and ether. The hands and
external clothing of the surgeon and his assistants should be
sterilized, also the towels, suture materials, instruments, and
dressings.
Lawson Tait was the first to teach the great value of absolute and
mere cleanliness. This applies in large degree to the hands of the
chief operator and of the assistants. With a large amount of
scrubbing and cleansing of the hands it is not possible to put them
into a condition of ideal sterilization. This is perhaps more true of the
hands of some than those of others. A realization of this fact has led
to the introduction of gloves, either thin rubber or cheap cotton. The
former may be used repeatedly. The latter are sterilized by repeated
boiling and may then be used again. Rubber gloves may be
sterilized by steam or boiling water, and may be cleansed with soap
and water or one of the stronger antiseptic solutions. The
introduction of rubber gloves has brought great improvement in
results. The gloves, however, constitute an impediment to some of
the finer work and the easy recognition of tissue. Not the least
important of the advantages of rubber gloves is the protection they
afford to the surgeon’s hands and to other patients. Many accidental
infections may be saved the operator if his hands can be kept out of
pus, while the use of gloves permits the operator to pass from a pus
case to a clean one without exciting fear. A snugly fitting glove is
best drawn upon the dry hand by the aid of sterilized talcum. But the
hand which it encloses should have been previously thoroughly
sterilized so that it will not be a source of danger should the glove be
pricked or torn. The operator can keep his hands in more favorable
condition by using gloves dry in this way than by macerating his
hands inside of wet ones.
The question of hand sterilization is an important one, whether the
gloves are to be worn by some or all of the operating staff. There are
occasions when it is important to make the hands absolutely clean
because no gloves can be procured. Even the hands encased in
gloves should be thoroughly prepared, as there is no knowing when
the glove may tear and the surgeon’s bare hand come into contact
with the patient’s tissues. Running water is preferable to a basin
filled with it, for while it runs it carries away such material as may be
detached by soap or nail-brush. If it be not possible thus to wash the
hands, then repeated basins of sterilized water should be used, and
all the crockery or metal ware used in the process should be
sterilized, so that the hands will not be contaminated by handling
unsterilized material. Nail cleaners are essential agents, to be
vigorously used, and nail-brushes should be sterilized after each
using, and there should be a separate brush for each operator. The
common soaps and even the officinal green soap are not sterile. The
former should be relied on only for the first cleaning, and the latter
should be sterilized before use. A dirty hand should not be thrust into
a receptacle containing freshly sterilized green soap. The outside
coating of dirt should first be removed by an ordinary soap.
Vegetable fiber has been recommended by many, but it is not as
good as ordinary corn-meal, which should be sterilized before using.
It is not as gritty nor as keen as sand, and yet it is sufficiently rough
to serve admirably the purposes of a curry-comb. A first scrubbing
with common soap and a nail-brush, followed by green soap with
corn-meal, and this by a thorough use of the nail cleaner and a clean
nail-brush, will ordinarily serve to put the hands in a reliable
condition. It is the practice of some to add antiseptics to the soap,
e. g., lysol and thymol. A number of years ago I introduced ordinary
mustard flour for this purpose, basing its use upon the fact that the
essential oil of mustard is one of the most potent of the vegetable
antiseptics, in addition to its power as a deodorizer. (Parenthetically
it may be said that when unpleasant odor attaches to the
unprotected hands after making a postmortem examination, or
opening an offensive collection of pus, the use of mustard will quickly
remove the taint.) Even mustard is not absolutely reliable, nor is
anything else which can be tolerated by the human skin. A method
much in vogue a few years ago was to wash the hands in a solution
of potassium permanganate, and then to decolorize the skin in
another strong solution of oxalic solution. This method was at one
time regarded as an effective one, but it is severe upon the skin.
Another method in use at present combines commercial chloride of
lime with saleratus; here free chlorine is supposed to be the active
agent.
The bacteriological side of this subject has been investigated by
numerous observers, particularly Dr. E. R. McGuire, attached to the
Buffalo Surgical Clinic, who reached the following conclusions:
Absolute sterility of the hands is unattainable, but as toward this
result nothing takes the place of long and vigorous mechanical
scrubbing under aseptic precautions; the use of antiseptics on the
skin is of questionable value and often distinctly harmful; the
operator whose hands perspire freely should wear gloves in every
case; the use of rubber gloves is not ideal, but gives the nearest
approach to it.
No material should be used which is so harsh that it will injure or
destroy the epithelial cells either upon the operator’s hands or upon
the patient’s skin.
Solutions of gutta-percha in its different solvents, or of collodion in
acetone, have been suggested as forming a covering for the hands
by quickly drying upon the skin. The merit of these preparations is
questionable, and the length of time required to dissolve the coating
makes them impracticable. They have found little favor among
surgeons.
Next to the sterilization of the parts to be operated, and the hands,
may be considered treatment of septic tissues or fluids and
protection against further infection. Clean and uninfected tissues
need no other precautions than those already described, plus extra
care in hemostasis, in order that there be no clot left in which germs
may find a nidus, and the careful closure of the wound in such a way
that no cavities or “dead spaces” may be left in which blood may
later collect. Surgeons generally agree that the less clean tissues are
handled and the less contact they undergo with foreign materials the
more readily they heal. The ideal fluids with which to cleanse parts or
to wash away blood clot are sterile salt solution and boiled water.
Antiseptic solutions should not be used upon healthy tissue; but
when abscess cavities have been opened and when pus or other
infectious material have come in contact with fresh raw surfaces,
every effort should be made to overcome its effects. It is customary
in abdominal operations to “wall off” the site of a pus focus so that
contamination of adjoining surfaces may be avoided, by placing
gauze packing around it. Other expedients, e. g., the use of a rubber
dam in any of its modifications, which will aid in this purpose, should
be adopted. Upon brain surfaces, as upon the ruptured perineum,
and in vaginal, rectal, and numerous other operations, a continuous
fine stream of salt solution may be directed with great benefit.
An abscess of any kind, no matter where located, should be
thoroughly cleansed, its cavity disinfected, and easy access made to
the outer wound. The interior of such cavities should be scraped with
a sharp spoon. After curetting, a thorough washing or swabbing,
often with the use of hydrogen dioxide, will often prove serviceable.
Even a treatment of this kind does not afford as complete
disinfection as may be secured by free application of pure carbolic
acid or of a strong solution of zinc chloride (50 per cent.). The effect
of this is not only to more completely sterilize, but to so sear the
cauterized surfaces as to make them incapable of absorption.
Excess of the caustic should be wiped away, or antidoted, in the
case of carbolic acid by further swabbing with alcohol, or in the case
of zinc chloride by merely washing out. Such a surface should heal
naturally after sloughing, yet it is rarely safe to completely close such
a cavity. A light packing of clean gauze, or, as the writer is fond of
using it, of gauze sopped in balsam of Peru, will permit such a cavity
to quickly close by the granulation process without further
disturbance. Bone cavities, especially, are well treated with zinc
chloride, it being difficult to so thoroughly disinfect such a focus that
it may be safely closed without drainage; or they may be filled with
bone chips or paraffin.
Visible tissue which is sure to slough should be removed with
scissors or the sharp spoon, in order to save valuable time.
Sometimes the actual cautery may be used to great advantage, as in
chancroidal buboes, where every particle of raw surface will be
infected by the pus which flows over it, and where it is advisable to
cauterize not merely the suppurative focus, but everything which
may come in contact with its pus.
Instruments.—Instruments are now all made of metal, usually
nickel-plated, which will stand at least a certain
amount of exposure to heat. It is not sufficient, however, to sterilize
instruments alone, but basins, irrigator nozzles, and everything else
which may be wanted during the course of an operation should be
equally prepared for it. Inasmuch as hard rubber does not well stand
even boiling water, instruments should be made, so far as possible,
of metal or of glass. Boiling water, or “live” steam, are universally
employed for this purpose; while to the water is often added 1 per
cent. of ordinary washing soda, which enhances its serviceability.
Fifteen to twenty minutes’ actual boiling, or its equivalent, will be
sufficient for ordinary purposes. All instruments, such as knives and
scissors, deteriorate after repeated use in this way and need to be
frequently sharpened. Catheters also may be sterilized by boiling
and should be constantly kept exposed to some volatile antiseptic,
such as formalin (see above). Sterile material should be used upon
the inhalers, and the metal parts of these, as well as mouth-gags,
hypodermic syringes, and the like, should all be boiled.
Dressings, etc.—Not only the dressings which are to be
employed after an operation, but the gauze, the
cotton, or the sea-sponges which may be used during the same
should have been twice sterilized either by dry heat or steam, in
order to ensure security. No absorbent material should be packed
tightly if it is to be subjected to steam, as it is not easily penetrated,
even under pressure. Moreover, not only these materials but the
sheets, gowns, aprons, towels, splints, and everything which may
come into near approach or actual contact with the wound should be
prepared in the same way. After sterilization all these materials
should be enclosed in germ-proof, sterile wrappers of some kind or
in sterile jars or boxes.
As a postoperative precaution, all materials which can be
destroyed after use in a septic case should be burned. If this be not
practicable, they should be soaked for twenty-four hours in a strong
solution of corrosive sublimate, say 1 to 500. At the conclusion of
operation there should be no opportunity left for dissemination of
infection.
Sponges.—In place of sponges, gauze or absorbent cotton
wrapped in gauze are now generally in use, prepared as
above. There are some purposes for which sea-sponges are very
convenient if they can be made reliable. Those which are received
fresh from the dealer should be freed from sand by beating in a
mortar, placed in a solution of 1 to 500 of potassium permanganate,
and then transferred to a solution of sodium sulphite containing 5 per
cent. by volume of pure hydrochloric acid; in this they remain until
they are bleached out, which will take but a few minutes. They are
then thoroughly washed in sterile water and stored in 5 per cent.
carbolic solution.
Suture Materials, etc.—Wire, silkworm-gut, horse-hair, and silk or
linen thread may be sterilized, if not rolled
too tightly, by twice boiling for a half-hour, and then being allowed to
dry, or preserved in 5 per cent. carbolic solution or in sterile alcohol.
Disappointment often comes from rolling these materials so tightly
upon spools that sterilization of the deeper layers is not complete.
This is true of catgut as well as of the other animal sutures.
Catgut.—Catgut, so called, is usually made from the intestine of the
sheep, and must be freed from anthrax germs or spores. It should be
rolled loosely on spools or rods, each layer separated from that
beneath by a piece of gauze. The writer prefers to free it from animal
fat by a preliminary soaking in ether or benzene. After this it may be
sterilized by boiling in alcohol, preferably absolute, which must be in
a container not tightly closed. This is placed in water, raised
gradually to boiling, and should boil for two hours. This process
should be repeated at least once after the expiration of twenty-four
hours. This is the simplest of all procedures and generally proves
reliable. Other methods are those of exposure, for instance, to
cumol, a volatile paraffin oil, in which it is boiled under pressure in a
special apparatus, the temperature being raised considerably above
the boiling point of water (300° F.). When the receptacle is opened
the cumol is drawn off or evaporates and the catgut is left dry and
sterile. It should be either kept dry in a sterile jar or in alcohol. Some
prefer to add to the latter a small amount of oil of juniper, which has
a little hardening effect upon the animal material.
Catgut should be tested repeatedly to be assured of its sterility.
Special methods of preparing catgut are as follows:
Formalin Gut is prepared by placing the gut, wound as mentioned, in
a 3 per cent. formalin solution for three hours. If the sterility of that
which is used be not assured, then this preparation should be boiled
in water for fifteen minutes. Catgut of large size should be immersed
in a solution stronger than the above. It will probably be sufficient to
give this a final boiling at the time of operation. This is almost as
lasting as chromicized gut.
Chromicized Gut.—Gut to be thus prepared should be wound in
single layers on spools and immersed in a solution of potassium
bichromate 1.5 to 2.5, carbolic acid and glycerin each 10, and water
1000 parts. It is allowed to remain in this solution for twenty-four
hours, then dried and boiled in water, or in alcohol under pressure, in
which it is subsequently stored. According to the length of exposure
and the strength of the solution, this gut will resist absorption from
ten to thirty days.
 Iodine Gut is growing in favor with some surgeons. It is prepared by
immersing catgut in a 10 per cent. solution of iodine, in which it is
kept for a week. After removal it is allowed to dry and is stored dry,
but should be kept protected from exposure.
Silkworm-gut may be boiled in a 2 per cent. lysol solution for one
hour, which makes it pliable. Sometimes it is convenient to have it
stained black in order that the sutures may be better distinguished
when removed. In this case it is allowed to stand in a 1 per cent.
silver nitrate solution for from twelve to twenty-four hours. This gives
it an almost black stain, but tends to make it more brittle. It may be
kept in alcohol, or dry in a sterile receptacle.
Silk.—Silk should be spooled loosely, boiled in a similar solution for
one-half hour, and again in plain water just before using. It may be
stored dry or in alcohol. It may be also stained black.
Celluloid Thread.—This should be washed and scrubbed in green
soap and hot water, after which it is spooled, and then boiled for
thirty minutes. It may be stored dry or in alcohol. This is a linen
thread covered with a film of celluloid.
Kangaroo and Reindeer Tendons are prepared essentially as is catgut,
but if boiled in alcohol they must be kept covered with the fluid, as
they tend to disintegrate.
Drainage Tubes of rubber should be boiled in soda solution for fifteen
minutes, and may then be stored either in 1 per cent. formalin
solution, or dry in a suitable tube.
Oiled Silk and Rubber Tissues are first prepared by washing in 1 to
500 sublimate solution, then dried, and exposed in an air-tight jar to
the vapor of formalin or paraform.
The above are the methods usually in vogue in the writer’s clinic,
and may be relied upon. These materials should be frequently tested
by dropping fragments into culture tubes and watching the result, but
only after taking the precaution to precipitate or neutralize the
antiseptic previously used in their preparation.
Antiseptic Solutions, Applications, etc.—In well-regulated
clinics sterile salt
solution is always at hand. As has been stated the old six per mille
solution may be improved by adding 1 part of potassium chloride and
2 parts calcium chloride. For emergency purposes tablets are now
prepared which will permit the rapid preparation of these, of any
desired strength. To this a little corrosive sublimate may be added
without producing decomposition. When sublimate is used alone, or
in other combinations, a little vegetable or mineral acid, such as
tartaric or hydrochloric, should be added, as most of the water used
contains lime.
When a maximum of bactericidal effect is desired with a minimum
of irritation, the silver salts, either the lactate or the citrate, will
probably afford the best results. The former may be used as strong
as 1 to 300, the latter 1 to 500. The writer has frequently used these
solutions for washing out the peritoneal cavity, in cases of
tuberculous peritonitis, where they serve their purpose admirably.
For washing out tuberculous joints and many other abscess cavities,
solutions of silver nitrate of 1 to 1000 to 1 to 2000 are most
serviceable; or, for the same purposes, boiled water, to which has
been added sufficient tincture of iodine to give it a mahogany color.
In caring for such cases it is good practice to alternate the solutions,
using them on alternate days.
Antiseptic powders or applications in dry form are useful for many
purposes. At one time iodoform was very popular; it was supposed
to act by virtue of the iodine set free in the presence of decomposing
organic material. It is now seldom used, partly because of its tell-tale
odor, and partly because of the disappointment which its use often
brings. It is, moreover, an active toxic agent of itself, and has many
times given rise to symptoms of intoxication, such as mental
depression, delirium, nausea, and anorexia. Under all these
circumstances free iodine can be detected in the urine.
There are numerous substitutes for iodoform, many of which are
superior to it in antiseptic properties, while most of them are free
from odor and toxic qualities. Two substances, however, are used
extensively—naphthalene and bismuth subiodide or red iodide. The
former has a marked odor and is more or less volatile, which makes
it particularly valuable. The latter is odorless, non-toxic, and of much
greater value as an antiseptic than most of the others, because it will
give off free iodine under favorable circumstances. A good plan is to
use it in the preparation of gauze and dressings, as well as for a
dusting powder upon the skin.
 The absolute value of these local applications is questionable,
because a wound will sometimes heal under the protection of a
piece of foil or gutta-percha tissue as well as when dressed in any
other way. This is true only of wounds in part surgically clean.
Drainage.—Drainage has been resorted to, more or less
intermittently, since earliest historical times. It is
provided for the removal of deleterious fluids or of superfluous
exudates or transudates. It is a recognition sometimes of a
necessity, at other times a confession of fear which may or may not
be justified. It is bad practice to cover a focus of previous gangrene
or suppuration in such a way that the infected cavity is closed to the
escape of accumulating fluid. This may be prevented by the use of a
suitable drain. At times a clean operation may be made, and yet in
such loose tissue, or to such an extent, that it is preferable to provide
for the escape of blood rather than let it occur and force apart
surfaces which should be in close contact. A drainage tube may
serve as a vent through which blood may escape that has oozed
after closure of the wound. After pelvic operations provision should
be made for the withdrawal of accumulating fluid which might serve
as a culture medium for germs. Drainage is therefore necessary in
many instances.
It will suffice sometimes to suture loosely a part or the whole of a
wound, so that should tension occur from retention there may be
spontaneous escape. This may be termed indirect drainage, and
sometimes has to be made still more complete by leaving out some
sutures, or by placing secondary sutures, which are only utilized
some days later, when previously infected surfaces have become
healthy and are granulating, so that they can be brought together.
By direct drainage secretions and fluids are guided toward the
dressings, which should be absorbent or so arranged as to provide
for their accommodation; thus in drainage of the gall-bladder or of
the urinary bladder the tube may be connected with a suitable
receptacle by siphonage. Capillary drains may be made of a few
strands of silkworm-gut, which is non-absorbable, or of catgut, which
is absorbable, and to which, perhaps, no further attention need be
paid. This will answer for conducting away small amounts of fluid
which exude. Gauze, or its equivalent in the shape of some form of