CHAPTER XL.

Operating-room.—The operating-room should bewell lighted from the top and at least one side. If a good natural light cannot be secured, an electric drop-light will be found very convenient. For work deep in the pelvis or the abdomen a good light is essential. If necessary, light may be directed to the desired point by means of the ordinary head-mirror.

The floor, walls, and ceiling of the room should be of some non-absorbing material. There should be in the room no appliances whatever that are not essential for the performance of the operation.

The interior of the room should be wiped throughout with a mop or with wet cloths, or, still better, flushed with the hose, in order to remove and lay all dust. The room may be wiped throughout with a solution of bichlorid of mercury (1:2000). At the Gynecean Hospital the operating-rooms are disinfected once a week with formaldehyd gas.

The temperature of the room should be not less than 75° F. Shock from bodily loss of heat and exposure of the peritoneum is diminished if the atmosphere of the room is at an elevated temperature.

Apparatus.—All apparatus, such as basins, tables, etc., should be of such a character that it may be sterilized by boiling or by washing with a solution of bichloride of mercury (1:1000). Glass-top tables with painted or nickel-plated frames are preferable. The operating-table should be so arranged that the patient may be placed in the Trendelenburg position (Fig. 193). This position permits the intestines to gravitate out of the pelvis, and is very useful in many operations. There are a great variety of tables in use. Before the Trendelenburg posture was introduced the writer used for several years a plain hard-wood plank supported by two wooden horses. The Boldt table is very convenient. With it there is no necessity for a rubber pad for catching fluids. It is applicable for all gynecological operations. Some operators are in the habit of dressing the operating table by placing on it a blanket and sheet. This is unnecessary, unless the patient is in such a condition of collapse that it isessential to preserve all bodily heat. The blanket usually becomes saturated with fluids and serves no good purpose.

The number and arrangement of the basins, tables, stands, etc. used in an abdominal operation are shown inFig. 194.

The basins are best sterilized by boiling, or by washing with scalding water (inside and outside) and a solution of bichloride of mercury (1:1000).

The tables and stands are sterilized by washing with the bichloride solution. If wooden-top tables are used, they should be covered with a towel wrung out of a 1:1000 bichloride solution.

Fig. 193.—Trendelenburg position.

Operator, Assistants, Nurses.—Usually one assistant, who stands opposite the operator, and two nurses, are sufficient. A second assistant, standing beside the operator, is useful to thread needles and to hand instruments and ligatures. The operator, assistants, and nurses should possess such general cleanliness as follows a morning bath. They should not attend any patients suffering with a septic or infectious condition upon the day of the operation. If they have done so upon the previous day, they should subsequently take a generalbath and change all clothing. Care in this respect is especially desirable on the part of the nurses, whose long hair prevents easy cleansing of the head.

Fig. 194.—View of the sterilizing and operating rooms of the Gynecean Hospital, Philadelphia. The apparatus is arranged for operation.A, flasks of sterile water;B, jar containing silk ligatures in glass tubes;C, instrument-sterilizer containing boiling water;D, tray containing sterile water for instruments at operation;E, basin for washing sponges;F, basin for washing hands of operator during operation;G, tray for sutures, ligatures, and needles;H, jar of cold sterile water;J, kettle of hot sterile water;K, water-sterilizer;L, dressing-sterilizer.

The operator and assistants should wear sterilized outer clothes—cotton shirt and duck trousers. A large sterilized apron put on immediately before the operation is an additional protection. The nurses should wear large sterilized aprons over freshly washed, if not sterilized, dresses.

The hands and forearms of the operator, assistants, and nurses should be bare and especially sterilized. The finger-nails should be short, rounded, and smooth. A long nail is difficult to clean, and in the case of the operator is dangerous, as it may lacerate important structures in the process of enucleation of a tumor. Enucleation of adherent growths is best done with the blunt finger, which passes along the planes of separation. The sharp nail may perforate an intestine or lacerate a blood-vessel, instead of pushing it aside.

The nails, fingers, hands, forearms, and lower part of the upper arms should be thoroughly scrubbed with frequently changed hot water and soap (preferably soft soap) and a large stiff nail-brush. The process should not be done hastily or but once. The soap should be repeatedly washed off and renewed. Five minutes, at least, should be devoted to the scrubbing. The hands and arms should then be similarly scrubbed with alcohol, and finally scrubbed with a solution of bichloride of mercury 1:1000. Immediately before proceeding with the operation the hands and arms should be rinsed in sterile water.

There should be a nail-brush for each solution used. The brushes should be clean and sterilized by boiling or by placing in the steam sterilizer.

After sterilizing the hands, the operator, the assistants, and nurses should touch nothing which is not sterile. If they are obliged to do so, the hands should be again washed.

Rubber gloves, such as are used in general surgery, arevery useful in the operations of gynecology. They may be worn to protect the patient in case the operator or the assistants are not certain of the sterility of their hands, or to protect the operator when working upon a septic patient. Rubber gloves should be sterilized in the steam sterilizer.

Sterilization of Dressings, Towels, etc.—The operating-cloths, aprons, sheets, towels, dressings, gauze pads, etc. are most conveniently sterilized by steam heat. The temperature should be at least 100° C. (212° F.). The dressings and bandages should not be too tightly packed, so that all parts may be exposed to the same temperature.

Several kinds of steam sterilizers have been introduced. The most easily obtained is the Arnold sterilizer. An apparatus like the Sprague sterilizer, in which the steam is superheated, is preferable, but, as it is not portable, it is adapted only for hospital use.

The dressings should be maintained at the elevated temperature for an hour or more. Although this method secures very good sterilization, yet there are certain spores which resist such elevated temperature even after a two hours’ exposure. The method offractionalordiscontinuous sterilisationhas therefore been introduced. Two or three successive sterilizations are practised at intervals of twenty-four hours. Spores which at first escape destruction will have developed into vegetative forms in the intervals, and are destroyed by the final sterilizations.

At the Gynecean Hospital all dressings are sterilized for three consecutive days for two hours each day. The dressings, towels, etc., after sterilization, should be preserved in sterile glass jars or other sterile receptacle.

Sterilization of Instruments.—Instruments, drainage-tubes, catheters, and any rubber appliance may be sterilized by boiling in water for fifteen to thirty minutes. A dilute solution (1 per cent.) of carbonate of soda is preferable, as the instruments are not so easily rusted, and this solution, when boiling, has greater germicidal qualities than plain water.

Very convenient instrument-sterilizers are made, in which the instruments are contained in a tray that may be lifted out and placed in the receptacle for containing the instruments during the operation. This receptacle or pan should itself be sterilized, and should contain sterile water, or preferably the sterile solution of bicarbonate of soda, in sufficient quantity to cover the instruments.

It is very convenient to keep on hand a saturated solution of carbonate of soda, sterilized by boiling, a small quantity of which may be added to the water in the instrument-tray. Rusting of instruments is diminished by this means.

Appliances that are injured by moist heat or by steam may be sterilized by thorough washing and soaking in a solution of bichloride of mercury (1:1000). It is useful to keep a large vessel of such a solution on hand, in which apparatus that is not injured by the bichloride may be placed.

The Water.—The water used during the operation, for washing the wound, the abdominal cavity, the sponges, and the hands of the operator and assistants, should be sterilized by boiling or by distillation. The water should be boiled for two hours a day on two consecutive days, or it should be boiled under pressure as in some of the modern water-sterilizers. If the water contain a perceptible sediment, it should first be filtered.

Very convenient water-sterilizers are made, from which the water may be drawn of any desired temperature, after having been both filtered and sterilized by heat. There should always be a large quantity of sterile hot water at hand. Water below the temperature of the body should not be introduced in the peritoneal cavity, and pads brought in contact with the intestines should be wrung out of hot water.

About fifteen gallons of sterile water are usually required in an abdominal operation.

The water should be preserved in sterile pitchers, basins, or other receptacles.

Glass flasks are very convenient for containing the water with which the abdomen or pelvis may be washed out. The water may be poured directly into the abdomen from the flask. The flask should be plugged with non-absorbent cotton to prevent the entrance of dust.

Some operators prefer to use a normal salt solution (sodium chloride gr. 90 to water ℥xxxiiiss) for washing out the peritoneum. Such a solution is probably less irritating to the peritoneum than plain water.

If the flasks are used for containing the water, it may be boiled in them, and then preserved by plugging with absorbent cotton until required at the operation. The temperature of the water used for abdominal irrigation should be 100° to 115° F.

Sponges.—In the minor operations about the vagina or uterus the field of operation may be kept clean by irrigation with sterile water or by the use of sponges. Small sponges in holders are commonly used. These sponges, after being washed free of sand and bleached if necessary, may be sterilized by soaking for twelve hours in a solution of bichloride of mercury (1:500). They should then be rinsed in warm water and preserved in a 3 per cent. watery solution of carbolic acid, which should be changed every week.

Artificial sponges, or gauze sponges, are the most convenient in abdominal surgery. They are cheap, and may be destroyed after each operation, and they are very easily and certainly sterilized in the steam sterilizer. Good marine sponges are so expensive that but few operators destroy them after they have been once used. The cleansing and sterilization of such sponges are tedious and uncertain. The gauze sponges answer every purpose.

The gauze sponges may be made of various sizes by sewing together about eighteen layers of plain absorbent gauze. The edges of the gauze should be folded in and hemmed to prevent the escape of loose threads in theperitoneum. Some operators use sponges made by wrapping absorbent cotton somewhat loosely in gauze.

The number of sponges used should always be recorded before the operation. It is advisable to preserve the sponges in sets always of the same number, so that in every case the operator knows that this number, or some multiple of this number, of sponges has been used. The writer uses such sets of seven gauze sponges of the following sizes: one sponge 3 by 3 inches; one sponge 10 by 7 inches; five sponges 5 by 5 inches. Usually one such set of sponges is enough for an abdominal operation. In some cases, however, the first set of sponges may become soiled by the discharge from an abscess or a suppurating tumor, and it is advisable to discard these sponges and to complete the operation with a second clean set.

The number of sponges should never be altered during an operation by cutting one in two.

Sponges should never be removed from the operating-room until the abdomen has been closed and the sponges have been counted. If a sponge falls on the floor or in the vessel to receive slops, it should be put aside until the final counting is completed.

When a set of sponges is used, they should always be carefully counted as they are placed in the basin, for the nurse who prepared and put up the set may have carelessly miscounted them.

Accuracy in regard to the sponges is of the greatest importance. There are a number of recorded cases, and many unrecorded, in which sponges have been left in the abdomen. This accident is usually fatal, though there are several cases on record in which the sponge has made its way, by ulceration, into the intestine, and has been discharged from the anus, or has been removed by subsequent incision through the abdominal wall.

Discipline of the Operating-room.—The discipline of the operating-room should be most rigid. Perfect personal asepsis can be obtained only by continuouswatching and criticism. The work should be systematically divided among the assistants and nurses, and each should attend strictly to his or her own department, and to nothing else.

The first assistant should assist the operator with sponges, etc. The second assistant should attend to the instruments, ligatures, and sutures. The first nurse should wash the sponges and place them in a basin of sterile water beside the first assistant. She should also attend to the towels and dressings. The second nurse, under direction of the first, should change soiled water in the sponge- and hand-basins, etc.

No one should pick up anything that may have been dropped upon the floor, and no one, unless it is absolutely necessary, should touch anything that has not been sterilized.

Anesthesia.—With the exception of the operator, the anesthetizer is the most important person at an abdominal operation. A careful, experienced anesthetizer is desirable in all operations, but especially so in an abdominal operation. Much more depends upon him than upon the assistant. The custom of trusting the anesthesia to the least experienced man is reprehensible. Many fatal cases after celiotomy may be attributed directly to the anesthesia.

Every operator of experience has observed the difference in reaction between those patients who have been carefully anesthetized and those who have been improperly anesthetized. In a serious case attended by unavoidable shock the superadded depression of ether-poisoning may be enough to cause a fatal result.

The operator should have nothing to do with the anesthesia, and it should not be necessary for him to watch it. The anesthetizer should make a careful examination of the heart, and should be provided with a hypodermic syringe and the necessary stimulants, which he should use at his own discretion.

He should, of course, use the minimum amount ofether. He should be familiar with the steps of the operation, and he should so regulate the anesthesia that the operator will not be impeded by the straining or struggles of the patient at critical moments.

Preparation of the Patient.—It is always desirable, when possible, to have the patient under observation for several days before operation. As I have already said, a more accurate diagnosis may be made by repeated examinations, and opportunity is afforded for the administration of medicines to improve the general condition. A weak woman about to submit to a serious operation is benefited by the administration of 1/20 grain of strychnine three times a day, for several days before the operation.

During this period the patient should receive a daily bath, a laxative when necessary to produce a daily movement, and a vaginal douche of one gallon of hot water every morning and evening.

The special preparation of the patient is directed to sterilizing the abdominal surface, the external genitals, and the vagina, and to emptying the gastro-intestinal tract. This preparation should begin twenty-four hours before the operation. During this time it is best to confine the patient to bed.

Thorough evacuation of the intestinal tract is very desirable in abdominal surgery. When the intestines are empty and collapsed, the various intra-abdominal manipulations are most easily performed. If the intestine is injured and it becomes necessary to repair it, or if any other intestinal operation is required, it may be performed most easily and with the greatest cleanliness if the gut is empty.

Though it is impossible to sterilize the intestinal tract, yet we most nearly approach the condition of sterilization by thorough evacuation of the bowels.

Twenty-four hours before the operation purgation should be begun by the administration of 1 dram of Rochelle salts, dissolved in half a tumblerful of water or soda-water, every hour until the bowels begin to movefreely. Five or six doses are usually sufficient. The lower bowel should finally be emptied thoroughly by an enema of soap and water administered three or four hours before operation. During the twenty-four hours preceding operation the diet should consist of light, easily digested, concentrated nourishment, such as milk, buttermilk, soft-boiled eggs, rare beef, soups, beef-tea, coffee, tea, and whiskey if necessary.

Unless the patient is very weak, no food should be given on the morning of the operation. If her condition does not warrant such abstinence, she may have a glass of milk, buttermilk, coffee, or milk-punch. Such food is required if the operation is performed late in the day.

In very feeble patients a nutrient enema may be administered about two hours before the operation.

A hypodermic injection of 1/20 grain of strychnine is often useful upon the morning of the operation when the patient is in poor condition.

Preparation of the External Genitals and Vagina.—The pubis and the external genitals should be shaved. The woman should be drawn down to the edge of the bed, and the anus, the external genitals, and the vagina should be scrubbed with green soap. The vagina should be washed throughout. The nurse may do this by inserting one or two fingers, or she may retract the perineum with the Sims speculum, and scrub the vagina, the fornices, and the vaginal cervix with cotton held in forceps.

The scrubbing should be followed by a vaginal douche of a gallon of hot water to wash out the soap, and then by a douche of two quarts of bichloride solution (1:2000). One hour before operation the vaginal douche of bichloride should be repeated, and the nurse should introduce in the vagina as far as the cervix a light vaginal tampon of gauze wet with the bichlorid solution. In every abdominal operation on women it is desirable that the external genitals and the vagina should be clean. Itmay be necessary to pass the catheter or to perform some vaginal manipulation, or the vagina may be opened during the operation.

If the vagina is small or virginal, or if the woman is nervous, the nurse may be unable to perform the method of cleansing just described; and it is then necessary for the operator or the assistant to clean the vagina after the woman is anesthetized. Such cleansing should always be performed, in addition to the cleansing by the nurse, whenever a vaginal operation is performed or it is expected that the vagina will be opened from above. Thorough vaginal sterilization is most easily accomplished when the patient is under the influence of ether, as the perineum is easily retracted and the vagina becomes more patulous. The woman should be placed in the lithotomy position, and the washing should be performed with two fingers or with a soft brush like a jeweller’s brush, or with cotton in forceps. If necessary, the perineum should be retracted with the speculum. Green soap should be used, and the vaginal walls, the fornices, and the cervix should be thoroughly scrubbed. The soap should then be carefully washed out, and the scrubbing should be repeated with bichloride-of-mercury solution (1:2000).

The cleansing of the external genitals and the vagina is best done by the nurse after the final movement of the bowels and immediately before the woman has her general bath.

Sterilization of the Abdomen.—The patient should have a warm bath from head to feet upon the morning of the operation. The abdomen, from the ensiform cartilage to the pubis, should be scrubbed with a nail-brush. Special care should be devoted to cleansing the umbilicus. After this bath the patient should be dressed in a clean flannel undershirt and night-gown and should be placed in a clean bed.

The nurse should then wash the abdomen, from the ensiform cartilage to the pubis and from flank to flank,and the upper third of the anterior aspect of the thighs, first with turpentine, second with green soap, and finally with ether, devoting special care to the umbilicus. The abdomen should then be covered with a large wet bichloride dressing (1:2000), which should not be removed until the patient is upon the operating-table. A towel wrung out of the bichloride solution and held in place by a bandage or binder will answer the purpose. A second cleansing of the abdomen by the operator or the assistant should be done after the patient is upon the table. The surface should be washed with green soap and sterile water, then with ether, and finally with the solution of bichloride of mercury. The washing should not be restricted to the central abdomen, but should extend over the upper parts of the thighs and the flanks, which may be exposed during the operation.

Fig. 195.—Tait’s hemostatic forceps.

Fig. 196.—Spencer Wells’ forceps.

The bladder should be emptied by the catheter immediatelybefore the patient is placed upon the operating-table.

The patient should be placed upon the operating-table by clean nurses or assistants.

The legs should be strapped to the table. The hands should be held out of the way by the anesthetizer. They may be retained very well by a safety-pin passed through the lower sleeve and the shoulder of the night-gown or the pillow-case.

The undershirt and night-gown should be drawn well up behind, to prevent wetting. If the clothes become wet, they should be changed immediately after operation.

The legs and the chest should be covered with clean blankets. The field of operation should be surrounded by sterilized towels. One large towel with a hole of suitable size in the center is convenient. A pocket may be made immediately below the hole, to retain the instruments when the Trendelenburg position is employed.

Fig. 197.—Knife.

Instruments.—The number and the variety of instruments used by the gynecologist in abdominal operations depend a good deal upon the taste of the individual operator. The list given here comprises all the instruments that are found useful by the writer in abdominal work:

Three sizes of twisted silk are used for suture and ligature: heavy silk for ligature of the large arteries; medium silk for ligature of smaller vessels and for various suturing in the abdomen; fine silk for peritoneal and intestinal suture.

Fig. 198.—Pedicle-needle.

The silk should be as small as is consistent with secure ligature. The heavy silk is necessary for the ligature of pedicles in which a large amount of surrounding tissue is included with the artery.

Fig. 199.—Small curved trocar.

The silk is rolled on glass spools or on cores of gauze, contained in glass tubes plugged with cotton, and is then sterilized in the steam sterilizer by fractional sterilization. It is advisable always to use, for heavy ligature, silk of a uniform size, because the operator becomes accustomed to the strength of the silk and knows just how much strain it will bear. Silkworm-gut is the best material to use for suture of the abdominal incision incase the “through-and-through” or interrupted mass-suture is employed.

The silkworm-gut should be of the heaviest and the longest size. It may be sterilized by boiling with the instruments before the operation.

Fig. 200.—Large cyst-trocar.

Catgutis sometimes employed for ligature and suture. The difficulty of securing certain sterilization makes it advisable to avoid using this material within the peritoneal cavity. Sterilized silk is so certainly absorbed in all cases and is so easily employed that the writer has altogether given up the use of catgut within the peritoneum. It is useful as a buried suture for the muscle and fascia of the abdominal wall. Silk is not so certainly absorbed in this position, and if the catgut should happen to be imperfectly sterilized, no worse result than suppuration of the incision will occur.

Fig. 201.—Reiner’s needle-holder.

Various methods of sterilizing catgut have been introduced. The writer uses the following method, which bacteriological experiments and clinical experience have shown to be good: The catgut is soaked in juniper oil for one week. The oil is then washed out with ether and the catgut is soaked in ether for forty-eight hours.The gut is then rolled on glass spools and is placed in a glass jar containing pure alcohol. The alcohol is boiled in the jar for an hour at a time on several successive days. The gut is used directly from this jar, and is always boiled in the alcohol for an hour before each operation. In this way, if a considerable amount of gut is prepared at one time, it is subjected to many boilings before it is used up. The alcohol is boiled by placing the glass jar in a vessel of hot water.

The following methods of sterilizing catgut are also good:

The Claudius or Iodin Method for the Sterilization of Catgut.—Cut the catgut into the desired lengths and wind on glass slides or spools. Place in a wide-mouth jar with a glass stopper containing a solution composed of iodin and potassium iodide, each one part, and distilled water 100 parts. In making this solution the iodin and potassium iodide should first be pulverized in a mortar, the distilled water should be added, and stirred with the pestle until solution is complete.

At the end of eight days the catgut is sterile and ready for use. It may be kept indefinitely in the solution without deterioration. Before using take the catgut from the jar with sterile forceps and rinse in sterile water.

The Cumol Method for the Sterilization of Catgut, employed at the Johns Hopkins Hospital.—1. Cut the catgut into the desired lengths, and roll 12 strands in a figure-of-8 form, so that it may be slipped into a large test-tube.

2. Bring the catgut gradually up to a temperature of 80° C., and hold it at this point for one hour.

3. Place the catgut in cumol, which must not be above a temperature of 100° C., raise it to 165° C., and hold it at this point for one hour.

4. Pour off the cumol, and either allow the heat of the sand-bath to dry the catgut, or transfer it to a hot-air oven, at a temperature of 100° C. for two hours.

5. Transfer the rings with sterile forceps to test-tubes previously sterilized as in the laboratory.

The cleanest specimens of the crude catgut should be obtained for surgical purposes. There is no doubt that some specimens of crude catgut are more difficult to sterilize than others. A special apparatus has been introduced for sterilizing catgut which renders the process safe and certain.

The writer uses catgut only for suture of the abdominal fascia and muscles. Large-sized gut is employed.

The Dressing.—The dressing of the abdominal wound consists of ten or twelve layers of sterilized gauze, covered by a large sterilized abdominal pad about 1 inch thick, 13 inches long, and 9 inches broad. The pad is made of absorbent cotton enclosed in a layer of gauze. The dressing is retained in place by a six-tailed sterilized abdominal binder of flannel.

If no drainage through the abdominal incision is employed, the use of celloidin with the gauze dressing is of advantage. It retains the dressing securely in position for an indefinite period, and, if used liberally, it acts as a splint for the abdominal wall. Either of the two following formulæ given by Robb may be used:

Mix, and add of Anthony’s “snowy cotton” enough to give the solution the consistence of simple syrup.

The celloidin should be poured over the edges of the first layers of gauze that are placed upon the wound.

Abdominal Drainage.—Drainage of the peritoneum is accomplished by means of the glass drainage-tube (Fig. 202), or by capillary drainage with gauze. The peritoneum may be drained through the abdominal incision or through the vagina. On account of the difficulty of keeping the vagina sterile, drainage through the abdominal incision is the safer method. Vaginal drainage is preferred when the operation is performed through the vagina and no abdominal incision is made, as in the operation of vaginal hysterectomy.

Fig. 202.—Glass drainage-tube.

The glass drainage-tubes should be of various lengths—5 to 7 inches. The outer diameter should be about ⅜ or ½ inch. The lower portion of the tube is perforated with small holes over a distance of about 1½ inches. Around the upper part or neck of the tube, which protrudes from the abdomen, is placed a square of rubber dam, such as is used by dentists, about 8 by 8 inches in size. The tube passes through a hole in the center of the rubber. The tube and the rubber dam may be sterilized by boiling. The tube is usually placed in the lower angle of the abdominal incision, and the abdominal dressing is split so that it may be placed around the tube. The bandage is applied so that the four upper tails pass above the tube and the two lower tails pass below it. The opening of the tube and the rubber dam are outside ofthe bandage. When the dressing and bandage have been applied, the opening of the tube is plugged with sterile absorbent cotton, and a handful of cotton is placed in the dam, which is then folded over and pinned. A sterile towel is placed over the dam. Some operators insert a cord of cotton or a few narrow strips of gauze to the bottom of the tube, in order to maintain a continuous capillary drain.

Cleansing or emptying the drainage-tube is a procedure which should be very carefully attended to. Strict asepsis should be observed in all the manipulations. For the first few hours the general peritoneum is exposed to danger of infection every time the tube is opened. After the first twenty-four hours, though the danger of general peritoneal infection is remote or absent, yet there is always danger of local infection of the tube-tract. Such local infection may result in a persistent sinus or other complication. A ligature near to or in contact with the tube may become infected, and the sinus will remain open until the ligature is discharged.

The tube may be cleaned by any careful nurse. The bedclothes should be drawn down to the pubis and the clothing should be drawn up, so that the abdomen is exposed. Sterile towels should be placed about the rubber dam. The hands of the nurse should be sterilized. The dam should be opened, the cotton should be removed, and the orifice of the tube exposed. The tube should be emptied with the long-nozzled syringe (Fig. 203), or with some other easily sterilized apparatus by which the fluid may be withdrawn.

Fig. 203.—Syringe for cleaning drainage-tube.

All fluid should be withdrawn from the drainage-tube. The dam should be carefully cleansed by wiping with cotton wet with the solution of bichlorid of mercury. A fresh cotton plug should be inserted in the tube, andthe dam should be folded and pinned over a handful of cotton. The whole should then be covered with a sterile towel.

The tube should be emptied or cleaned as often as it becomes filled. It is often necessary at first to clean it every fifteen, thirty, or sixty minutes. If free bleeding is taking place, it is most quickly arrested by frequent cleaning of the tube. Unless the nurse is experienced, the operator or assistant should watch the drainage-tube for the first hour after operation, in order to direct the nurse in regard to the required frequency of cleansing. A record should be kept of the amount of fluid withdrawn.

The intervals between cleansings are gradually increased until once every six or twelve hours becomes sufficient. It is not often necessary to keep the tube in the abdomen longer than two or three days.

The tube should be removed when the fluid discharged becomes serous in character and small in amount—about one dram every four or five hours. Before removing the tube the flannel binder should be opened and the wound should be exposed. When the glass tube is withdrawn, it is best to replace it by a small rubber tube. This may be done by inserting the rubber tube to the bottom of the glass tube, which is then withdrawn. If we were certain that the tube-tract were aseptic, the introduction of the rubber tube would be unnecessary, and we might close the lower angle of the incision immediately by suture. This procedure, however, may be followed by fluid-accumulation and the formation of abscess in the tube-tract. It is therefore safest always to use the rubber tube. The rubber tube should be withdrawn gradually, an inch or two every day, so that the tract will close from the bottom. In order to prevent the rubber tube slipping altogether into the drainage-tract, it is advisable to insert a small safety-pin through the extra-abdominal end. The end of the rubber tube should be surrounded and covered by several layers of gauze and the abdominal pad.

Gauze-drainage.—Capillary drainage with gauze issometimes more convenient than drainage with the tube. A strip, about 2 inches in width, of several layers of gauze should be carried, from the part of the pelvis to be drained, out through the lower angle of the abdominal incision. When the sutures are introduced the lower angle of the incision should not be too tightly closed, or drainage will be impeded. The extra-abdominal end of the gauze drain should be surrounded and covered by several layers of loosely-packed gauze and by the abdominal pad and binder. Sterile cotton should be tucked under the binder immediately above the pubis, and, if necessary, around the upper and lateral margins of the pad. The dressing need not be disturbed for one, two, or three days, unless the discharge has soaked through the abdominal binder.

A convenient capillary drain is made of a gauze bag containing several strips of gauze.

One objection to the gauze drain is the difficulty of removal. Lymph-processes and granulations penetrate the interstices of the gauze, and often render its removal very difficult. The surgeon fears to use too much force in attempts at withdrawal, because an adherent loop of intestine or the omentum may be pulled out of place or damaged, or the lymph-wall of the drainage-tract may become opened and expose the general peritoneum to infection. To avoid this difficulty the writer has for some time employed a drain made by surrounding the gauze bag with an ordinary rubber condom the end of which has been cut open (Fig. 204). With this arrangement the surgeon may feel certain that there are no adhesions except at the end of the drain. Such drains may be removed as easily as the glass tube. The condom may be sterilized by boiling. Gauze drains should be removed at the end of two or three days. After withdrawing the gauze it is advisable to insert a small rubber tube, for reasons that have been mentioned in considering the use of the glass drainage-tube.

The gauze drain may be used in all cases except when it is necessary to drain pus or some solid material likefeces. In such cases the glass tube should be employed, either alone or surrounded by a gauze pack to protect the general peritoneum.

In pelvic surgery the drain, whether glass or gauze, should, as a rule, be placed at the most dependent part of the pelvis, which is the bottom of Douglas’s pouch. It may be placed to either side of the median line in case the chief discharge is expected to take place from this position. Hemorrhage from a bleeding surface deep in the pelvis may often be controlled by the direct pressure of the end of the gauze drain placed over it.

Fig. 204.—Gauze drain with rubber cover.

The drain should be introduced immediately before the abdominal sutures are tied.

Indications for Drainage.—Great diversity of practice exists among operators as to the use of drainage after celiotomy, and a decided change has taken place in regard to drainage during the past twenty years. In the early days of modern abdominal surgery drainage was used very much more than it is at present; some of the best operators used it in the majority of their cases; now a number of operators never use drainage after celiotomy, while others use it only when specially indicated. Much depends upon the individual methods of the operator. The operator who is careless in his asepsis and hemostasisshould use drainage oftener than he who is careful in these particulars. The advice, “When in doubt drain,” is very good; but the surgeon should strive to eliminate the element of doubt as much as possible, and to have a definite reason for all his procedures. If drainage is not necessary, it is harmful. It necessitates more frequent dressings and disturbance of the patient, and it prevents perfect closure of the abdominal incision.

The object of drainage is the removal from the peritoneum of discharges which are, or which may become, septic or dangerous. Such discharges are blood, pus, serum, cyst-contents, and ascitic fluid.

Even though the peritoneum be dry and all bleeding be arrested when the operation is completed, yet it must be remembered that a subsequent free serous exudation will take place if the peritoneum has been exposed or subjected to chemical or mechanical irritation.

Infection may take place from imperfect asepsis at the time of operation; or it may be caused by the escape into the peritoneum of septic material which existed in the abdomen before the operation; or it may occur subsequently, from the passage of septic organisms from the interior of the intestine through the intestinal wall.

The absorbing power of the healthy peritoneum is so great that a large amount of fluid (even though not absolutely sterile) may be taken up by it. Injury of the peritoneum from exposure or other irritation not only increases the amount of fluid to be absorbed, but it diminishes the power of absorption; and injury of the intestinal peritoneum or of the wall of the intestine favors the passage of septic organisms through it.

The operator should bear these facts in mind when he considers the subject of drainage.

A certain amount of absorption of blood or other sterile fluid may be trusted to the peritoneum.

It is sometimes impossible to arrest all venous oozing from raw surfaces, and the blood must be left for absorption by the peritoneum, or must be carried off by drainagewith the glass tube or with gauze. Drainage enables the operator to watch the amount of hemorrhage after operations, so that if excessive he may employ measures to check it. Drainage also acts as a hemostatic. The direct pressure of the gauze upon the bleeding area checks the hemorrhage, and the continual removal of blood, the promotion of dryness, and the contact of air through the glass tube have a decided hemostatic effect.

Drainage, therefore, is sometimes used not only to remove blood, but to aid in arresting hemorrhage. As the operator becomes more experienced he practises more perfect hemostasis, and learns to obliterate by buried suture, to fold in, or to cover with peritoneum raw bleeding surfaces, so that drainage as a means of hemostasis is less often required. If the operator fears that the peritoneum has become infected from imperfect asepsis at the operation, or from the escape into it of some septic material like pus, he should employ drainage, especially if he expects much subsequent serous or bloody discharge to take place.

If the intestinal wall has been extensively injured, as we sometimes find after an adherent intestine has been liberated, drainage should be employed; for septic organisms most readily pass through such an injured wall, and the damage may be so great that necrosis may take place, with the escape of intestinal contents. It must be remembered that all purulent accumulations in the abdomen and pelvis are not septic. Such accumulations were septic in the beginning, but in the majority of chronic cases the septic organisms have died and disappeared, and the pus is perfectly sterile and harmless to the peritoneum. Consequently, if an ovarian or a tubal abscess ruptures during removal, and the contents escape into the peritoneum, drainage is not necessarily required. For a period of three years the writer had in such cases immediate bacteriological examination of the pus made, and determined drainage from the result of such examination. In the majority of cases the pus wassterile and drainage was not employed. It has been found, as would be expected, that the pus is most often septic in the cases of recent suppuration and in the chronic cases during an acute attack. Experience also teaches that suppurating dermoids are very likely to be septic.

It will be seen from these considerations that in determining the question of drainage much must be left to the judgment and the experience of the operator.

If an aseptic operation has been performed, and there is no intestinal lesion and hemostasis is perfect, drainage is not required. This condition of things is, of course, most often attained by the experienced operator. If the operator fears septic infection for any reason, or fears that the hemostasis is not good, he should employ drainage. At the present day the decided majority of the best operators use abdominal drainage very little.

When general peritoneal sepsis exists before the abdomen is opened, drainage is always indicated.

Vaginal Drainage.—Drainage of the peritoneum through the vagina is usually accomplished by making an opening through Douglas’s pouch into the posterior vaginal fornix. A rubber drainage-tube or a gauze drain may then be inserted. The vagina and vulva should, of course, have been thoroughly sterilized. The vagina should be lightly packed with gauze, and the vulva should be protected by a gauze and cotton dressing. As has been said, the chief objection to vaginal drainage of the peritoneum is the difficulty of sterilizing and maintaining sterile the vagina and the vulva.

The Incision of the Abdominal Wall.—The various abdominal operations of gynecology are performed through an incision in the median line. The position of the incision depends upon the condition to be treated. The incision for performing ventro-suspension of the uterus is made near to the symphysis pubis. The incision for the removal of a large cyst is made at a higher point. As a rule, the incision, about 2 or 2½ inches inlength, should be made about midway between the umbilicus and the pubis, and should be extended upward or downward as necessary. The incision should be as small as the operator can conveniently work through. He should not hesitate to enlarge the incision to facilitate any manipulations. The length will depend a good deal upon the thickness of the abdominal walls.

The structures that are incised are the skin, the subcutaneous fat, the parietal fascia, the linea alba or the edge of the rectus muscle, the subperitoneal fat, and the peritoneum.

If the incision is made exactly in the median line, the linea alba will be divided and the sheath of the rectus will not be opened. This is most usual in multiparous women with lax abdominal walls and widely separated recti muscles, and in cases in which the abdomen is distended by a tumor. If the sheath of the rectus is opened, the muscle will be exposed, and the linea alba should be sought on the side upon which the fascia fails to retract.

If the linea alba cannot readily be found, the incision should be carried directly through the muscle. Some operators consider it an advantage, in obtaining subsequent firm union, to expose the muscle in this way. When the subperitoneal fat is reached, it should be torn and pushed aside with the blunt closed forceps or with the fingers.

The peritoneum should be caught with forceps and drawn forward. The assistant should catch the peritoneum with a second pair of forceps at a point about ⅓ or ½ inch to the side of the first pair, and the small fold of peritoneum thus produced should be incised with the knife. As soon as the smallest opening is made in the peritoneum the air rushes in and the intestines and omentum fall back. The opening is then enlarged with the knife or scissors.

The greatest care must be exercised in those cases in which the omentum or the intestines are adherent to theanterior abdominal wall. The experienced operator usually observes indications of such a condition as soon as he has passed through the linea alba. The tissues are more rigid and unyielding than normal, and the peritoneum cannot be readily picked up with the forceps. In such cases the operator should proceed very slowly, and if necessary should enlarge the outer incision and enter the peritoneum at a point above or below the area of adhesion.

Exploration of the Abdomen.—Having opened the peritoneum, the operator should insert two fingers (the middle and the index finger of the left hand) and should carefully examine the condition to be treated.

If necessary, he should retract the edges of the incision, and should place the patient in the Trendelenburg position, in order to make an ocular examination.

It is always advisable to make a preliminary investigation of this kind before proceeding with the operation. In this way the diagnosis will be corrected and complications which must be treated will be determined. It may be found that what was thought to be a cyst is in reality a uterine fibroid or perhaps a normal pregnancy; or the surgeon may discover a hopeless condition, such as extensive cancer or peritoneal papilloma, for which further operation will be useless.

Protection of the Intestines and Omentum.—During all manipulations within the abdomen the peritoneum, intestines, and omentum should be handled most gently. Injury of the peritoneum increases the danger of shock, sepsis, and intestinal adhesions. The intestines should never be allowed to protrude through the abdominal incision unless it is necessary for the performance of the operation. Such a necessity rarely, if ever, arises in gynecological operations. All the intestines may be removed from the field of operation—the pelvis—by placing the woman in the Trendelenburg position. Protrusion of intestines through the abdominal incision should be prevented by using large gauze pads or sponges.It is advisable always to surround the field of operation by a wall of gauze pads. They protect the intestines and prevent the escape of fluids into the upper peritoneum. This precaution is especially desirable when the Trendelenburg position is used, to prevent fluids from the pelvis escaping into the upper abdomen. The pads should be introduced after being wrung out of warm water, and should be replaced by fresh warm pads as soon as they become saturated with fluid. If they become soiled by pus or other septic fluid, it is safest to discard them for the remainder of the operation.

Toilet of the Peritoneum.—The field of operation, and, if necessary, the general peritoneum, should always be cleaned and dried before the abdominal incision is closed. This is done by sponging and by irrigation with warm sterile water or with normal salt-solution. The sponging should be performed with great gentleness, to avoid peritoneal irritation. There are several regions in which fluids and blood-clots are most likely to collect, and which therefore demand especial inspection.

The chief of these regions is the hollow of the sacrum, or Douglas’s pouch. Fluids also collect on the anterior surface of the broad ligaments and in the renal hollows.

If but little fluid has escaped into the abdomen, and the field of operation has been confined to the pelvis, we need look for accumulations of fluid and blood only in Douglas’s pouch and in front of the broad ligaments. If the upper portion of the abdomen has been invaded, it is advisable to inspect the renal hollows. Blood-clot and fluid may be readily removed by the sponge held in the fingers or in forceps.

Irrigation of the peritoneum is not often required. It is not necessary to flood the peritoneum with water in order to wash out blood-clot, which may be removed with more accuracy by sponging. There is always danger, in general irrigation of the peritoneum, of spreading infection.

Local washing of the pelvis is sometimes advisable ifthe operator fears that the field of operation has been infected by the escape of septic material. Such a condition may exist in operations for tubal or ovarian abscess. The upper peritoneum should be first shut off from the pelvic cavity with a wall of gauze sponges. This may be readily done while the patient is in the Trendelenburg position. She should then be placed in the horizontal position, while the operator, with the left hand pressed against the wall of pads, prevents the intestines entering the pelvis. The abdominal incision should be held open with retractors, and the sterile irrigating fluid should be poured in from a flask or a pitcher. The temperature of the fluid should be 100°-115° F. The fluid may be removed by sponging, and washing may be repeated as often as necessary.

In septic cases the writer has frequently performed such local washing with a bichloride solution (1:2000 or 1:4000), followed by irrigation with plain water.

If the patient is horizontal and the gauze pads be properly placed, there is no danger of any of the fluid entering the upper peritoneal cavity.

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