REQUIREMENTS DURING OPERATION
SPONGES AND SPONGING
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 is to sponge. An enameled iron basin rack, as shown in
Fig. 12, answers the purpose best.
[Illustration: 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 hemorrhage by 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.
STERILIZATION OF DRESSINGS
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 in Fig. 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,
of injuring the instruments by excessive heat. To overcome this defect
the Wallace sterilizer may be advantageously employed.
[Illustration: FIG. 13.—WILLY MEYER STERILIZER.]
[Illustration: FIG. 14.—WALLACE STERILIZER.]
=Wallace Sterilizer.=—Its chief feature is the addition of a reservoir
fitting with the separated sterilizer into the outer body. See Fig. 14.
This reservoir automatically regulates the water and steam supply. It is
filled with water 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 in Fig. 15.
[Illustration: 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 degree
nearly 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 in Fig. 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.
[Illustration: 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 in Fig. 17, may be used, or, better still,
the same can be obtained in combination with an instrument table, as
shown in Fig. 18.
[Illustration: FIG. 17.—DRESSING CASE.]
[Illustration: 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 in Fig. 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.
[Illustration: FIG. 19.—WASTE CAN.]
SUTURES AND STERILIZATION
(_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, and for 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:
Bichlorid of mercury gr. vj;
Alcohol ℥x;
Distilled water ℥iiss.
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.
The _formaldehyd method_ of 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.
The _dry-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.
[Illustration: FIG. 20.—CLARK KUMOL APPARATUS.]
The _Kumol 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 in Fig. 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 sand bath; 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 catgut_ of 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.