CHAPTER IIIREQUIREMENTS DURING OPERATION

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 isto sponge. An enameled iron basin rack, as shown inFig. 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 hemorrhageby 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.

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 inFig. 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, ofinjuring 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. SeeFig. 14. This reservoir automatically regulates the water and steam supply. It is filled withwater 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 inFig. 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 degreenearly 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 inFig. 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 inFig. 17, may beused, or, better still, the same can be obtained in combination with an instrument table, as shown inFig. 18.

Fig. 17.—Dressing Case.

Fig. 18.—Combination Dressing Case and Table.

Waste Cans.—All soiled dressings and sponges should be immediately thrown into an enameled iron pail furnished for the purpose. At no time must soiled dressings or sponges be thrown upon the floor, where they are walked over, soiling the floor and, by drying, contaminating the air of the room. Cans for this purpose are made of steel, enameled, of the form shown inFig. 19.

The contents of the can must be taken from the room after each operation and burned. The can should be flushed with carbolic solution, and returned to the operating room.

Fig. 19.—Waste Can.

(Ligatures)

Silkworm Gut and Silk.—In plastic surgery silkworm gut and silk are used extensively. Rarely is ordinary catgut resorted to, because it is absorbed before thorough union takes place, besides being a source of infection, either primarily from imperfect sterilization or by taking it up from the secretions of the deeper layer of skin not affected by external antiseptics.

The sterilization of silk is accomplished by boiling it for one hour in a 1-20 carbolic solution and then keeping it in a 1-50 similar solution (Czerny). Or it may be boiled in water for one hour and retained in a 1-1,000 alcoholic solution of corrosive sublimate. Ordinarily it may, however, be simply subjected to boiling and steamed in the autocleve. Silkworm gut is treated in the same manner. It has greater tensile strength than silk, andfor that reason the thinner varieties are to be preferred to ordinary silk.

Catgut.—It is far more difficult to prepare catgut, but, since it is necessary for ligation, the following methods may be considered best:

The commercial catgut as made from the intestines of sheep, is wound snugly upon a rod of glass and thoroughly brushed with soft soap and hot water. It is then rinsed free of soap, wound upon small glass spools, and placed for forty-eight hours in a one-per-cent alcoholic bichlorid solution, composed of bichlorid of mercury, 10 parts; alcohol, 800 parts; distilled water, 200 parts. The turbid fluid produced by first immersion is changed. Before using, the spools are placed in a glass vessel contain containing a 1-2,000 sublimate alcohol (Schaffer), made up as follows:

These glass cases are obtainable for the purpose and contain a second perforated compartment for the ligatures passing through rubber valves placed into the openings (Haagedorn).

Catgut is generally prepared by soaking in oil of juniper for one week and then retaining it in absolute alcohol (Kocher), or a 1-1,000 alcoholic sublimate solution.

Another method for strengthening catgut, as well as to prevent its too rapid absorption, is to chromatize it. This is done as follows:

The catgut is placed in sulphuric ether for forty-eight hours, then treated for another forty-eight hours in a ten-per-cent solution of carbolized glycerin, followed by a five-hour subjection to a five-per-cent aqueous solution of chromic acid (Lister). It is allowed to remain in the latter forty-eight hours, then placed in an antiseptic, dry,tightly closed receptacle, and finally soaked in 1-20 carbolic solution before using.

Theformaldehyd methodof Kossman is to immerse the gut in formaldehyd for twenty-four hours, then washing with a solution of chlorid and carbonate of sodium and retaining it in the same solution. The catgut in this procedure swells and its strength is much impaired in this way.

Any of the above methods are not above criticism, however, rigid as they may seem, bacterial growths having been obtained with nearly all of them.

Thedry-air method(Boeckman, Reverdin) is reliable, but the subjection of catgut to dry air at a temperature of 303° F. for two hours results in making it tender and less pliable.

Fig. 20.—Clark Kumol Apparatus.

TheKumol method(Kronig) is considered the most reliable, even under the severest tests. This mode of sterilization is accomplished as follows: A specially devised apparatus of brass, with a cast-bronze top, both thoroughly nickel-plated, is used. The apparatus of J. G. Clark, as shown inFig. 20, will be found excellent. The kumol is retained in a seamless cylinder, 8 by 8 inches, which is surrounded on the sides and bottom by a sandbath; the flame, impinging on the bottom, heats the sand, thereby insuring an even heat to the inner or sterilizing cylinder. The catgut, in rings, is placed in a perforated basket hanging in the cylinder, which can be raised or lowered at will; after drying for two hours at 80° C., the basket is dropped, and the catgut immersed in the kumol, at 155° C., for one hour; the kumol is then drawn off through a long rubber tube, and the catgut dried at 100° C., for two hours; it is then transferred to sterile glass tubes plugged with cotton.

Prepared catgutof the various sizes can now, however, be purchased in the market, and that offered by the better firms of chemists is quite reliable and may be safely used for all plastic surgery about the face. It is supplied in glass tubes, either in given lengths, as in the Fowler type, in which the hermetically sealed tube is U-shaped or on glass spools placed in glass tubes, not sealed, but closed by a rubber cap, through which the desired length of ligature is drawn and then cut off.

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