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the pathology of the nerve cell, and of the cerebral arteries and veins, in. cluding syphilitic vascular lesions. The author recognizes the rough general classification of mental diseases which distinguishes the so-called functional disorders from the organic-degenerative types. Of the celllesions in simple insanities we have but the most vague ideas, beyond that during life we are able to note temporary congestions, vascular hyperæmias, and conditions suggestive of oedema cerebri, or the reverse, arterial spasm. These, however, are present in other conditions in which there is ordinarily no other evidence of grave cerebral disturbance, and the factor of heredity must be given due weight. But despite the fact that many points in a consideration of the pathological substratum of insanity are still obscure, there are sign-posts that point out the lanes and by-ways by which one may reach something approaching a high-road to the goal. In the various dementias, notably the paralytic form, in the states of exaltation and depression from gross lesion of the cerebrum, and in toxic insanities, a fair conception of some of the processes inducing mental diseases is to be ascer. tained. Foremost are changes in the vascular structures, ordinarily classed as periarterial, endarterial and atheromatous. By these changes the supply of nutrient plasma may be shut off to such a degree that the cell suffers from hunger, and, as in the last moments in the life of all tissues, a struggle to obtain nutriment ensues. This is shown clinically as a stage of excitement, after which the animal dies or becomes demented. Equally sure in results, but of slower progress, are the effects from damming back the return flow of the used nutrient plasma, which shows itself in effects upon the nerve cell of accumulated waste-tissue products.
In some of the acute mental troubles (delirium grave, febrile and confusional insanities) the chemical and bacteriological examinations of the blood and excretions have shown the presence of bacilli and poisonous substances, which have induced alterations in the cell sufficient to disturb its vital properties, shown clinically in excitement followed by some phases of stupor.
The lack of nutrient supply in cases of affection of the vascular system gives a distinctive pathology to the frequent types of dementia that begin after the middle period of life. In these slowly progressive vascular changes, we shall finally determine, from a pathological standpoint, the origin of the majority of the various types of the organic-degenerative forms of mental aberration, the first alterations in the vessels inducing the gradual change from full mental powers to the slight mental obliquities, irritability without cause, forgetfulness, perverted impulses and similar minor signs that stamp the beginning of the first stage. Later, when the lesions in the vessel-walls have progressed, the nutrient plasma, transuding through them, being altered both in quantity and quality, we find a rebellion of the brain cell to the lack of its accustomed food, showing itself in a stage of acute excitement; and lastly, when the nutrient supply has sunk to a point barely sufficient to maintain the cell alive, and chemical and histological alterations have been induced in its protoplasm, there results the final stage of terminal dementia.
MODERN METHODS OF PREPARING AND PRE
SERVING MATERIALS USED IN
SURGICAL OPERATIONS. *
By C. HARPER RICHARDSON, M.D.,
Instructor in Surgery and Assistant Demonstrator of Anatomy, Albany Medical
College; Surgeon to the South End Dispensary, Albany, N. Y.
Asepsis is the pass word to success in the surgery of the present generation. To no detail of surgical technique should it be more rigidly applied than to those operative adjuncts that we have come to speak of as "surgical materials.” That these are largely responsible for the success or non-success of an operation cannot be disputed. Commercially prepared articles are always open to suspicion; hence, if we would be conscientious in our relations with patients who entrust themselves to our care, we must prepare our own supplies. We cannot always control the conditions under which we operate but we can and should see to it that everything that comes in contact with them is absolutely aseptic. All materials used in surgical operations can be sterilized either by subjecting them to the action of formic aldehyde gas, superheated steam or boiling water. Everything excepting animal sutures, such as cat-gut, kangaroo tendon, etc., can be reliably prepared by means of one of these agents. In our fight against infection they have proved our strongest and surest allies.
By super-heated steam, we mean steam so confined that we get fifteen pounds to the square inch pressure and a temperature
• Read before the Medical Society of the County of Albany, December 13, 1899.
of 265°F. To obtain this some form of mechanical apparatus is necessary and I know of none more easily understood and operated than the one you see here represented (fig. 1). This autoclav, or sterilizer, consists of a cylinder with two jackets, or chambers, closed at one end, a tight fitting door at the other, with entrance and exit for the water and steam, controlled by means of several wheels and cocks. The material is prepared in the shape to be used, put into the
Fig. 1. inner chamber and the door screwed home. About two and one-half quarts of distilled water are poured into the outer chamber or compartment, through the funnel shaped tube on top, F and the cock turned off. The gas is lighted underneath which gives a blue flame from the long Bunsen burner. K About fifteen minutes are required for the water to boil. The small cock nearest the operator A is left open until the escaping steam announces that the water is boiling, when it is
turned off. The water and steam are now confined in the outer chamber. The pressure and heat are registered by means of the gauge.
When the desired amount is reached the safety valve B controls and maintains it at that point. The valve can be set to any pressure up to thirty pounds to the square inch, but fifteen pounds is sufficient for the sterilization of anything. The super-heated dry steam is now allowed to pass into the inner chamber where the articles are, by simply unscrewing the largest black wooden wheel at the back. E
After twenty or thirty minutes have elapsed, the large wooden wheel is screwed down, preventing any further entrance of steam into the inner chamber. This inner
chamber is emptied of steam by unscrewing the little wheel on the further side and to the
The steam now being confined in the outer chamber as in the beginning, serves the purpose of drying out the dressings, which requires about fifteen minutes. When the articles are removed they are perfectly dry and ready for use. It has been our custom to make up several packages at a time, containing sufficient gauze, cotton, and bandages, wrapped in towels for ordinary small cases about the office and for use in the South End
Dispensary; they are then sterilized and are Fig. 2.
always ready when needed. For abdominal cases, in country and private house work, containers, or cartridges (fig. 2) are very convenient. plete outfit for one abdominal operation is contained in each one. This includes two aprons, two caps, two pairs of lisle thread gloves, ten gauze sponges, two long tampons, six towels, one gauze sheet, one tube silk (four sizes), one tube containing twelve strands of silk worm gut (previously sterilized by methods soon to be described), one tube silver foil, some smooth gauze squares, five Gamgee pads, one abdominal bandage, and one dozen safety pins.
The container being perforated at the bottom and at the sides near the top, allows the steam to come in contact with everything contained therein; when removed from the autoclav, the cover is pressed tightly down which closes the row of holes
near the top. The ones in the bottom are closed by means of a little slide. A clean linen jacket is then drawn over the container and it is placed in a leather case (fig. 3) for convenience in carrying. It will be seen that the container is not opened at all until the cover is removed for use at an operation.
Gauze pledgets used for absorbing blood during operation, are made by taking pieces of gauze four inches wide and six inches long, folding them diagonally and tying in one flat loose knot.
Fig. 3. The corners or two ends are tucked in which leaves no free edge or selvage. Several glass cylinders (fig. 4), opened at both ends, covered by linen jackets, are filled with the pledgets and sterilized at the same time. They are always ready for any kind of an emergency. The sterili
Fig. 4. zation of ligature materials has been a subject of much discussion. If we are sure they are aseptic, the method of sterilization is a matter of choice. The following plans are used by us and have proved satisfactory:
Silk. Nos. 00, 0, 1, 2, 3, best China twist, are tightly wound from the skein
on metal (nickle plated) frames (fig. 5), two
inches wide by six Fig. 5.