« PreviousContinue »
temperature, while others require high degrees of heat; but live steam at its highest point, about 250 degrees, will destroy in time any of the known harmful bacteria. But as different degrees of heat are necessary to destroy different bacteria, so the time that this heat must be applied varies with the different kinds of bacteria to be destroyed. Then again, as we cannot sterilize each piece of gauze, and each sponge, and each particle of dressing by itself, and as these things must be massed in packages, for sterilization, the time of the application of the heat must be considered with reference to the size of the mass we are attempting to sterilize; for instance, if we take the ordinary laparotomy drum and fill it with dressings, and apply 250 degrees of steam, it will take a very much longer period of time to destroy the germs down in the middle of the package than those at the circumference. All these agencies and processes are matters of experience, each operating room staff mploying its own plant in the light of its experience, for achieving the desired end.
Then comes the proof that our sterilization has been complete, and the only proof is the culture medium and the microscope. There is one more proof, and that is the septic or aseptic condition of the wound of last week's operation, but that is expensive proof, especially for the patient, and more indirectly for the surgeon. Hence, in order that we may not have occasion to experience this proof or disproof, we must make the other investigation, that is, the culture medium and the microscope, not once, but periodically, repeatedly, often. For we have come to know that what was aseptic to-day, the process that gave us perfect sterilization yesterday will, for some reason or other, not give us perfect sterilization tomorrow or next week. Hence, the wise hospital administrator will prove the perfect asepsis of every vestige of his operative paraphernalia as often as his facilities will permit, and at least at frequent intervals.
In this connection I am taking the liberty to quote two reports from our pathologist, covering two different items in the operating room.
"July 25th, 1908.—Method of steam and dry sterilization in operating room :
1. It was found that the method of steam sterilization employed is very efficient. And that it is safe for the destruction of the very
resistant spores of bacillus mesentericus vulgatus. (These spores are more resistant than the spores of the tetanus bacillus.)
2. was found that dry heat as used in the operating room is simply a drying process, but has no power of sterilization. In two tests antherax spores, which are only moderately resistant to heat, were not killed. (Signed) MAXIMILIAN HERZOG, M. D.,
"September 24th, 1908.—Examination of method of sterilization of small dressing boxes :
In order to test the sterilization of the small dressing boxes, Petri dishes containing cotton saturated with sporulating anthrax bacilli and bacilli mesentericus vulgatus were placed in the center of a box filled with dressing material. The box so prepared was subjected to the usual method of sterilization. Subsequent cultural tests showed: 1. That all anthrax spores had been killed. 2. That the spores of bacillus mesentericus vulgatus had not all been killed.
From the tests it may be concluded that all such pathogenic bacteria as staphylococci, streptococci diphylococci, bac. pyocyaneus, diphtheria, typhosus, etc., will be reliably destroyed by the method of sterilization employed. However, the spores of tetanus which are more resistant than anthrax spores and less resistant than spores of bacillus mesentericus vulgatus, might survive. The probability of tetanus spores being present in the bandaging material is rather remote. (Signed) MAXIMILIAN HERZOG, M. D.,
The crucial factors in the surgical operation are: 1, the surgeon—and his ability to operate; 2, the sterilization of his field of operation, and 3, the anesthetic.
The principles and practice underlying the administration of chloroform and ether are so well understood from the surgeon's standpoint, and are so completely in his hand under the usual methods of procedure, that the interference and interest of the hospital manager are rarely if ever warranted; moreover, the physiological properties of these drugs and their physiological effects on the patient are so markedly independent of whatever mechanical appliances might be supplied in their aid, that their administration is almost wholly within the realm of the personal equation of the surgeon and his aids. The remaining anesthetic, recognized generally as such, nitrous oxide or laughing gas, is quite another matter, and we can do very much to help the surgeon in its proper and safe administration.
For very many years the use of laughing gas was confined to the dentist's chair, and it has never been and is not now considered either dangerous or difficult to anesthetize a patient for the few short moments required to draw a tooth. But of recent years the use of nitrous oxide has been so greatly extended that it is not an unusual occurrence with us to-day to keep a patient under its influence for two or three hours, and in the Michael Reese Hospital we have persisted in its employment continuously for three hours and forty minutes with a successful issue.
The physiological action of nitrous oxide is vastly different from that of chloroform or ether. Some of us can very well remember the frights and panics we had when we first began to use nitrous oxide in the more serious operations. We can see almost as a nightmare now the cyanotic skin, the pinched expression and the cold, clammy sweat of the patient who was taking his anesthetic badly. Doubtless many patients died at this stage of the anesthetic. We were disposed, in those days, to attribute such an anesthetic as that to some faulty physiological condition of the patient himself. We know now, perfectly well, that it was crass ignorance on our own part rather than the fault of the patient, and I think nowadays we can congratulate ourselves that deaths on the operating table from the use of nitrous oxide are things of the past. Of course we know that all those untoward symptoms in the patient in the old days were due to want of oxygen in the blood and that we were actually smothering the patient.
In the Michael Reese Hospital we have devised a mechanism which we find meets all the requirements for the administration of gas. Briefly it is as follows: There is a tank of oxygen and two tanks of gas set into one frame, any one of the tanks changeable at will; from the gas tanks a metal tube leads to a four-gallon reinforced rubber bag; leading from this bag is five fet of wired silk tubing that leads to a "Y"; a precisely similar arrangement leading to another similar bag and concluding at the same “Y” comes from the tank of oxygen; the mouth-piece or inhaler is fixed into the “Y." A simple arrangement of stop-cocks completes the apparatus, and the anesthetist, by the turn of a single stop-cock, can have at his command either pure gas or pure oxygen, or any percentage of an admixture of the two instantaneously. With this apparatus pure gas can be administered until there comes the first sign that the patient is taking it badly; in which case a small amount of oxygen can be mixed with the gas, and the experienced anesthetist, by carefully watching his patient, and using proper proportions of the two gases, can keep his patient completely under, and yet hold him perfectly in hand.
The question of where an anesthetic shall be started is attracting a good deal of attention, and most new hospitals are being constructed with an anesthetizing room just off each operating room. There seems to be some doubt of the advisability of such an arrangement. Undoubtedly it will save time where one surgeon is operating on many cases in a single room, for one patient can be anesthetized while the surgeon is concluding another case. In our own institution there seems to be a general feeling on the part of the surgeons, especialy in their private cases, that they would rather have the patient in their presence from the very outset, so that they can see him and hear him while they are cleaning up for the operation. This contemplates, of course, an ultra-individualism. Many surgeons clean themselves up at the beginning of their morning's work, and continue to work in the same gowns and the same gloves through their several cases. That is not the case with us, and it is the rule of the hospital that a complete change and a complete re-cleansing is made for each operation.
HOSPITAL PATHOLOGY. There is a mooted question in the medical profession whether a pathological laboratory should be maintained in its entirety in one department and at one location, or whether such simple procedure as blood counts, urinalysis, and the like, shall be conducted in small spaces in the wards. Most hospitals in this country employ one principal pathologist, or they employ part of the time of a member of the medical staff, who does the more highly technical work himself and who stands sponsor for all the work done in the institution, and whose aides are generally members of the
house medical staff in rotation. There is a good deal to be said on both sides of this question of the concentration of laboratory work. Most attending men prefer that their own internes follow their cases through the laboratory, in order that comparisons may be made between the findings of different dates, and in the light of the directions given by the attending man to his internes, so that the personal equation may be observed, rather than that examinations shall be conducted in a perfunctory manner, and such hard and fast rules as must obtain when all the work is done in one large laboratory. The system of small stations through the house would be ideal but for the fact that these young men are beginners, and cannot be expected to observe the finer points in microscopic and chemical work, and many things of advantage to the attending man and his patient are more than likely to escape them. Moreover, it is hardly possible for the pathologist to be responsible for an examination made at a distance from his own department, and under conditions which he would not at all approve. It would seem, therefore, that a happy conclusion on this point would be to have the routine work done under severely correct to have the routine work done under severely correct methods in the laboratory proper, and then to add to this work or supplement it with any personal examination in particular cases that the attending man may exact of his own internes; for instance, we know that two men may take a single slide for a white count, and get vastly ditferent results, and if a subsequent reading is taken for comparison, we will find that the two men are so far apart that the net result will be highly misleading to the attending man. But if the case has not been obscured, and one man has made all the readings, the attending man may be able to make his diagnosis easily, so far as his laboratory findings may aid him.
It is no business of the hospital administrator to interfere in the ordinary pathological work, as applied to individual cases, except to see that the laboratory and its assistants are efficient, well equipped, and that they do their work promptly and conscientiously. There is one branch of pathology, however, which I think we have not been paying quite as much attention to as it deserves, namely, the cleanliness of the hospital from the bacteriological standpoint.