_Elements of the Antiseptic Method._
_The purpose of Antiseptic Surgery is to avoid the occurrence of the
dangers of infection_ referred to in the preceding chapter. There are
many methods of carrying out the system, but the present description
being limited to the requirements of circumcision does not aim at being
exhaustive. The two objects aimed at are:
1) _The prevention of any micro-organisms gaining entrance to the
wound._ This end is attained by the disinfection of the hands and
especially the thumbnails of the operator, of the instruments
and dressings used; and by perfect cleanliness of the genitals
of the infant. It may be said that the brief exposure of the
parts during the performance of the circumcision carries with
it no risk of infection, because the organisms we have been
considering are not usually airborne.
2) _The application of such dressings as will keep the wound in
an aseptic condition._ Even the small amount of discharge from
a circumcision wound forms a splendid soil for the growth of
micro-organisms. It is necessary therefore to apply a dressing
which has been saturated with such antiseptics as will destroy
that constituent of the discharge which makes it a good culture
material.
The most convenient antiseptic for general use is _Carbolic Acid_. This
is a clear, colourless liquid of rather oily consistence, which rapidly
becomes converted into solid crystals in cold weather. When required for
purposes of disinfection it should be mixed with 39 times its quantity of
water, or roughly one pint of water requires one tablespoonful of pure
Carbolic Acid to make a solution of 1 in 40.
This solution is required for soaking the hands after they have been
washed with soap and warm water, and the nails scrubbed with a nail
brush. This latter proceeding is one of _ordinary cleanliness_, the
soaking in the Carbolic Acid solution, which should be warm, is in order
to obtain _Surgical Cleanliness_. It will be readily understood, that if
the hands come in contact with any possible source of infection after
this soaking, then it must be repeated before beginning the operation.
The disinfection of the hands must be the last stage in all the
preparations for the circumcision. A similar solution of 1 in 40 Carbolic
Acid may be used for placing the instruments in before the operation.
They are to be taken directly out of the solution as required. A shallow
dish of a material easily cleaned, as metal, glass or porcelain should
be filled with 2½ ounces (5 tablespoons) of water which has been boiled,
and to this one half a teaspoonful of Carbolic Acid is added, taking care
that the acid is thoroughly well mixed up with the water and not allowed
to float about in droplets.
If the instruments are scrupulously clean, i.e., if they have been
washed thoroughly with soap and hot water, they require to remain for
_one hour_ in the Carbolic Acid solution to render them sufficiently
disinfected for operating purposes. It is therefore quicker, as it is
also more scientific, to _sterilize the instruments before using them_.
By sterilizing them we kill any micro-organisms that may be present on
them, and we are then confident that no living germs are carried to the
wound by means of the instruments. In other words they are _aseptic_.
Instruments are sterilized by boiling for about ten minutes in clean
water. It is useful to add washing soda in the proportion of 5 grains to
every two tablespoons of water. It is obvious that the instruments must
be of metal, as no other material will stand boiling. They must be made
in such a way as to prevent the accumulation of dust or dirt in joints or
crevices.
Compact apparatus for sterilization is supplied by every surgical
instrument maker. The instruments are usually placed on a wire gauze
tray with handles and then into the sterilizing dish, so that when the
boiling is completed, they are lifted out on this tray by means of hooks
supplied for the purpose. They are at once transferred to the shallow
dish containing the 1 in 40 Carbolic Acid solution detailed above. By
these means the instruments are cooled ready for use, for obviously they
cannot be taken directly out of the boiling water with the fingers; and
the fact that they are in an antiseptic solution, prevents the access of
any germs during the short interval before they are actually handled.
The _dressings_ used in Circumcision should consist only of _lint_ and
_gauze_. It is necessary that the dressing should be sterilized and also
impregnated with some antiseptic so as to render harmless any infective
material which may accidentally contaminate the wound after circumcision.
These dressings are supplied by manufacturers, already sterilized by
exposure to super-heated steam, and rendered antiseptic by various
chemical agents. Carbolic Acid used for the hands and the instruments,
is often employed for the dressings, the antiseptic being fixed in the
lint and the gauze by a special process. Most surgeons, however, prefer
“_double cyanide_” dressings, in which the antiseptic used is a salt
known as cyanide of zinc and mercury.
From the first dressing until the circumcision is absolutely healed
nothing but gauze need be used. In a normal case no other application
of any kind whatsoever is required. It is usual however in applying the
first dressing at the circumcision to use lint to surround the root of
the penis as it is firmer than gauze. When this is done a piece of tape
is twisted round the lint to retain it in position. The tape and the lint
must both be sterilized like the gauze.
The best course to adopt in regard to the dressings is to obtain them
from a reliable firm of manufacturers, who will supply them ready cut to
the pattern required, packed in small sealed aseptic tin cases ready for
use.
Having adopted all these precautions the Mohel may be confident that
in regard to his own hands, the instruments, and the dressings he has
exercised every care which surgical science demands. The only other
important detail which demands attention is the part concerned in
circumcision. It is obvious that all the safeguards hitherto considered
are valueless unless the infant himself is in a perfectly clean
condition. The disinfection of the skin of an adult before an operation
is always a serious and difficult matter, because the skin harbours
so many micro-organisms, including the very micro-cocci referred to
previously. Elaborate measures are therefore employed for the skin
disinfection. But in the case of an infant the skin cannot be supposed to
be such a probable source of wound infection. It is sufficient that the
genitals be washed about half an hour before circumcision, with soap and
warm water, and subsequently a fomentation of Boracic lint applied. It
is as well to avoid the use of the various baby powders which nurses are
so fond of sprinkling freely on the folds of the skin. If it is thought
desirable to employ such a dusting powder, it should be a mixture of
equal parts of Boracic Acid and Starch.
The infant having been prepared as here stated, the circumcision may
proceed as soon as he is put in position. Should any soiling have taken
place, the infant must again be cleansed, and in this case the genitals
must be washed with the Carbolic Acid solution (1 in 40) by means of a
swab of cotton wool.
[Illustration]