ASEPTIC SURGERY.

CHAPTER I.

INTRODUCTION.

THE following notes are founded upon the demonstrations which I have been giving in the wards, and on Saturday afternoons in the operation theatre. They are merely "notes," and have no pretensions to completeness. They were jotted down at various odd times, and were published in St. Bartholomew's Hospital Journal, in the hope that they might be of use to those with whom I have to work in the wards and in the operation theatre. At present, the methods which I employ seem to be handed down by a kind of oral tradition, so that house-surgeons, dressers, sisters, and nurses are sometimes at fault to know what to get ready for operations, or how to prepare the required materials, or the patients. These points

will therefore be dealt with as simply and briefly as possible; and in doing so I will try and make clear the reasons upon which the various details are based. It is quite impossible to practise aseptic surgery with success, unless not only the surgeon and his assistant, but also the sisters and nurses, have a clear and distinct knowledge of its principles. Moreover, they must all possess a firm conviction of the truth of those principles.

This conviction does not grow in a day, but comes gradually, as we see that aseptic surgery is founded upon reason, is capable of proof, and gives the results which were promised.

DEFINITIONS.

Before we discuss the two great principles of aseptic surgery, the meaning of certain words which must often be used ought to be defined. First, I refer to the words "septic" and "aseptic," and it will be seen that both here and elsewhere various references will be given to what others have written. Those who wish to dip deeper into this subject, and to know it better, are advised to consult these authorities themselves, and not to take them at second-hand.

There can be no doubt but that the word "septic "

had originally its literal meaning and was applied to wounds which had the odour of putrefaction (ońπew: to make rotten or putrid). This was evidently the sense in which it was used by the authors of the Pathological Society's Report upon septicemia and pyæmia in 1879,1 and by all the earlier writers upon surgery. Further, it was а matter of common observation that these septic wounds were prone to be associated with septicemia, pyæmia, erysipelas, hospital gangrene, and so forth. In consequence, these diseases were often referred to as septic diseases, because they occurred when wounds became putrid.

Cases were observed, however, in which septicemia or pyæmia occurred without any decomposition of the fluids in contact with the wound.2 The discovery of more exact methods, especially Koch's invaluable method of cultivating bacteria upon solid nutrient media,3 such as gelatine, or agar-agar, explained this mystery, and showed that many of the bacteria of

1 Trans. Path. Soc. London, vol. xxx. p. 1 et seq.

'Pathological Society's Report," ibid., p. 29.

"Mitth. a. d. k. Gesndhtsamte.," Berlin, 1881, Bd. i. S. 18. Translated by Victor Horsley, for New Sydenham Soc., 1886.

4 The gelatine is the same kind as that which is used for making the ordinary jelly which is served at table. It melts at about 25° C., or a temperature a little higher than summer heat. Agar-agar is a firmer kind of gelatine, which bears a much higher temperature, and melts at about 50° C.

septicemia and pyæmia caused no odour of putrefaction.

On the other hand, many of these bacteria reveal their presence by causing inflammation and suppuration, so that pus became an important indication. At the present time I believe it is correct to say that most surgeons would call a pus-producing wound "septic," quite apart from the occurrence of a putrid odour.

Used in this way, it is clear that the word "septic " has been divorced from its original meaning, and implies that the wound is infected with pyogenic bacteria, which, it is to be remembered, are also capable of causing pyæmia, septicemia, and other grave affections. Pus is, however, rather a crude test of wound infection. I have often, by means of culture experiments, ascertained the presence of bacteria, such as Staphylococcus aureus or Streptococcus pyogenes, in wounds many hours before any pus appeared. There are some who hardly recognise pus unless considerable quantities are present. Those who are accustomed to inoculate culture media from the wounds which they have treated, know that the slightest moisture is a highly suspicious circumstance, and nearly always implies infection.

There is yet another class of wounds which is