CHAPTER IIREQUIREMENTS FOR OPERATING

The ideal operating room for the plastic surgeon need not necessarily be large, since it requires less work to render it aseptic. Furniture and possibly amphitheater accommodation are always a means of infection unless scrupulously cleansed, a task of time, difficult at best.

The room should be provided with large windows, with facilities for the introduction of the air from without. Two doors, and those well fitted, are all the room should have—but one being used, if possible.

The Walls.—The walls should be of plaster, smoothly laid and well painted, so that they may be readily washed down with antiseptic solutions—a daily morning rule. Glass or tiled walls are much used now and add considerably to the appearance and safety of the room, as plaster in time will crack, while the paint, owing to the heat of sterilizers or steam, often creeps and blisters, exposing an absorbing surface which readily wears down, exposing parts inaccessible for even acute cleanliness.

The Floors.—The floors of these rooms are now usually laid with tile mosaic or marble or a composition resembling linoleum. The base should be curved and all corners sloped off to improve drainage and to keep off dust and dirt.

Skylight.—A skylight of metal and glass is a valuable accessory. It should be fixed or never permitted to be opened during an operation.

Disinfection.—Spraying the room with an antiseptic is hardly necessary, since all germ life descends to the floor and can best be removed by washing with a 1-1000 bichlorid solution.

Should it be necessary to perform an unusually extensive operation in a private house, the room must be cleared of all furniture, pictures, drapery, and carpet. After plugging up the crevices in the windows and doors it should be well fumigated either with sulphur candles, as now commonly furnished, or, better, with formaldehyd.

The superiority of formaldehyd as a disinfecting agent is now well established. An illustration of an apparatus, largely doing away with the difficulties and dangers encountered in the use of the older and ordinary styles of the pressure or nonpressure type, is shown inFig. 3. The main difficulty with these has always been their almost inaccessibility for cleansing purposes, and in such where this is not the case, the size of the aperture has been made so small that the inside could not be reached. In the pressure apparatus the tops are bolted on, making them exceedingly difficult to remove, with the result that the necessary cleaning was not properly attended to. The corrosive action of formaldehyd gas is such that under these conditions any apparatus would soon become useless.

In the type shown a single clamp arrangement is used (a). By the turning of the hand screw (b) two planed metal faces (the upper surface of the boiler and under surface of the cover) are brought together and sealed. When the cover (c) is removed the entire inside of the boiler is in sight and can be thoroughly cleansed, which should be done each time the apparatus is used. The pipes through which the formaldehyd gas passes after generation are arranged so that they can be taken off and cleaned.

Fig. 3.—Formaldehyd Disinfecting Apparatus.

The gas is generated in the boiler (d) and passes out from the top, down through the pipe (e), and from thence through a series of pipes (f) underneath the boiler, which are subjected to direct heat from the lamp (g). By this means the gas becomes superheated, the polymerization of the formaldehyd is almost entirely prevented, and a dry gas is insured and given off at the pipe (h).

The room should be left closed overnight and thoroughly aired thereafter. The bare floor must then be scrubbed with hot water and soda and flushed with a three-per-cent carbolic-acid solution.

As little furniture as possible should be found in an operating room, and this preferably of undecorated enameled iron.

Instrument Cabinet.—For the instruments and dressings there should be a dust-proof cabinet of iron and glass, such as is shown inFig. 4.

Fig. 4.—Instrument Cabinet.

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

Fig. 5.—Operating Table.

Instrument Table.—An instrument table, such as is shown in the next illustration, is quite necessary, upon which dressings and instruments are laid during operation.In this the frame is of white enameled iron and the top and shelf of plate glass.

Fig. 6.—Instrument Table.

Irrigator.—An irrigator is often of service, especially in washing out the fine pieces of bone resulting from chiseling or drilling. In skin-grafting it may be used with sterilized three-per-cent salt solution as described later. The best irrigators are those of germ-proof or ground-glass stopper type. They are suspended from the wall by means of an iron bracket or pulley service or placed upon a movable enameled stand as shown inFig. 7.

Irritating antiseptic solutions are to be avoided, their especial indication will be found under antiseptic care of wounds.

Fig. 7.—Irrigator.

All instruments should be of modern make, devoid of clefts or grooves, and having separating locks when possible. Wooden or ivory handles should be entirely discarded.They should first be rendered free of dirt or dried blood by scrubbing briskly with a stiff nailbrush and hot water; then dried and placed in the sterilizer. The immersed instruments are boiled for five or ten minutes. There are many of such sterilizing apparatuses to be obtained, all made on the same plan, however, and consist of a copper or brass box and cover well nickel plated. Folding legs are placed beneath. A perforated tray is placed within for the immersion of instruments. An alcohol lamp with asbestos wick furnishes the heat.

One per cent of carbonate of soda added to the water prevents them from rusting. The simple subjection of instruments to carbolic-acid solutions or antiseptics of like nature is useless. (Gärtner, Kümmel, Gutch, Redard, and Davidsohn.)

From the sterilizer the instruments are placed in a glass tray containing a one-per-cent lysol solution. Knives, needles, and scissors should be immersed in a tray with alcohol, as a great number of antiseptics destroy their cutting edges. Glass or porcelain trays are best for this purpose. A sterilized towel being placed in the bottom of each for the better placing of instruments.

After operation all instruments should again be scrubbed with soap and hot water, immersed a moment in boiling water or a jet of live steam, dried with an aseptic cloth, and returned to the case.

A very effectual means of rendering instruments sterile is to place them in a metal box and bake them in the ordinary oven (200° F.) for one hour.

To preserve needles Dawbarn advises keeping them in a saturated solution of washing soda. Albolene has an unpleasant oiliness, but is otherwise good. Calcium chlorid in absolute alcohol is efficacious, but expensive. All rust accumulating on instruments must be carefully removed with fine emery cloth; this, however, is unnecessary if the soda solution is used as previously mentioned. It is well to occasionally dip the instruments (holding them with an artery forceps) into boiling water as they are used during operation.

Fig. 8.—Instrument Sterilizer.

The hands of the surgeon and his assistants must always be thoroughly prepared before operation or dressing a wound. The mere immersion of the hands into an antiseptic solution is not sufficient to removegerm life. The oily secretions of the skin and its folds, as well as the cleft about the nails and the nails themselves, are common carriers of infection and are cleansed only by the vigorous method of scrubbing with soap and water and then rendered aseptic by the use of proper media.

The aseptic hospital washstand, as shown inFig. 9, will be found an ideal piece of furniture; it has a frame constructed of wrought iron, white enameled. The top is of one-inch polished plate glass, with two twelve-inch holes.

Fig. 9.—Aseptic Washstand.

The entire stand can be moved away from the wall, to permit of thorough cleaning of basins, supply pipes, etc. The basins are the best annealed glass, and are supported by nickel-plated traps, with connections for vent pipes. The water supply is controlled by foot valves, which enable the operator to draw either cold, medium, or hot water at will. The waste is also controlled by a foot valve, as shown.

The systematic law of cleansing the hands should be insisted upon at all times. Rules for the method followed might be displayed in abbreviated form in the operating room by glass or enameled signs hung on the wall over the basin and reading as follows:

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

YOUR HANDS

Green soap is commonly used and is to be preferred to powdered or cake soap. The powder cakes and clogs the container in damp weather, while the latter collects impurities from the air. Synol soap, also liquid, is perhaps the most ideal, a two per cent solution of which forms an excellent lavage for cleaning instruments, as well as washing down furniture in the operating room.

The brushes to be used are of the common wooden-back, hard-bristle make, which can be boiled without injury. There should be several of these, marked on their backs as desired, so that one brush can be used for the one purpose only. In cleansing the hands, the forearms, and even the elbows, should be similarly treated. After scrubbing with soap, as directed, they are to be rinsed, dried with a sterilized towel, again scrubbed with alcohol, and then dipped or flushed with a bichlorid solution.

No woolen garments should be allowed to come in contact with the site of the operation, nor is it well to allow such material in the operating room while working.

Freshly laundered linen gowns of Von Bergman’s pattern, reaching to the shoes, should be worn. Theyshould contain half sleeves and be buttoned on the back. SeeFig. 10. These may be sterilized in the steam sterilizer or washed in one-per-cent soda solution. When soiled or blood-stained they should be relaundered.

The operator may substitute the gown with a rubber apron of the Triffe pattern, reaching as high as the collar, but continuous washing quickly ruins them. SeeFig. 11.

Fig. 10.—Von Bergman Operating Gown.Fig. 11.—Triffe Rubber Apron.

Fig. 10.—Von Bergman Operating Gown.

Fig. 11.—Triffe Rubber Apron.

The patient for all plastic operations should be carefully examined as to general health and past history. His healing powers should be at their best, as much depends on primary union. If he presents a syphilitic history,it is well to place him under treatment, for a time, at least, before an operation is undertaken. The bowels should be regular. Sulphate of magnesium should be given each morning, before breakfast, for at least two days prior to operating, while his general condition may be improved by the employment of bitter and alterative tonics. Nux vomica with tinct. cinchonæ com., associated with essence of pepsin aromat., or lactopeptone, are very useful. This treatment is also carried on for several days,post operatio.

The success of an operation depends, first, upon the selection of the case; second, the selection of the method employed, and, third, upon the hygiene under which the patient undergoes convalescence. The patient must be given to understand, in many cases, that it is often necessary to reoperate, even to the extent of seven or eight operations, to bring about the desired result. The first result obtained with many cosmetic operations is not at all gratifying to the patient, and unless this is explained to him beforehand he may become discouraged awaiting the next operation and disappear, thus losing the opportunity of being pleased finally, while the surgeon is misunderstood and underestimated by narrow-minded judges and the ever-willing friendly advisers and critics—a consummation much to be avoided.

The part to be operated upon should first be closely shaven. The oily secretions of the area are next rubbed off with an absorbent cotton sponge saturated with alcohol or ether. Next, the skin is washed with hot water and soap or three-per-cent synol suds, then rinsed, and finally rendered aseptic with a bichlorid solution.

If the operation is to be done about the face a rubber cap is so adjusted as to cover the hair. If this is not obtainable sterilized bandages can be employed.

In operations about mucous membranes, as in the nose and mouth, the parts must be cleaned at short intervals with a solution of permanganate of potash or boric acid. The teeth must be cleansed with antiseptic soap, tartar is scraped off, and the mouth rinsed with a proper disinfectant. The corrosive sublimate, or carbolated solutions, owing to their toxic qualities, cannot be used. The preparation of wounds for reoperation, or where an operation is secondary to injury, is referred to later.

All clothing about the site of operation should be removed and rubber cloth placed to surround the field and cover the clothing. This should be covered again with sterilized towels. Everything that touches the patient after this has been done should be aseptic; indeed, hands employed during operation must be immersed from time to time in 1-500 bichlorid solution, and allowed to remain wet.

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