The Preparation of the Sponges, Silk, Instruments, Gauze, and Water.The sponges were those prepared by Schorse, of Milwaukee. The silk was boiled an hour in a 5 per cent. carbolic acid solution, and in some cases afterward immersed in a solution of iodoform and ether and again sterilized by moist heat in a bottle stoppered with cotton. This was done by placing the bottle in a pail containing 1 inch of water and boiling for an hour. The instruments were boiled an hour in a 5 per cent. carbolic solution on the day before the operation and then dried. On the morning of the operation they were again boiled for a few minutes in a similar solution, and placed in trays of terilized water for use. The water was sterilized by boiling in large tin cans, each holding 2 or 3 gallons, for an hour or more on three successive days. The cans had tin covers, put on over a rim of cotton to stop the crack between itself and the can. The culture-medium used for these investigations was sterilized, alkaline, peptonized beef-tea gelatin. Most bacteria will grow in this medium at the temperature of a living room. Answers have been sought through these investigations to the following questions: 1. Are the sponges sterile when rinsed out and ready for use? Pieces of each of the sponges to be used were cut off by the assistant who had the care of them, and put into the gelatin with sterilized forceps. Three or four pieces were put in a single tube. In this tube you see 3 such pieces surrounded and permeated by the transparent nutrient gelatin. Out of 25 sponges from 7 operations, only a single sponge was found infected with a single colony. Through attempted cultures from these prepared sponges and silk, answers to the following questions have been sought: 2. Are the sponges sterile when ready for use? After the sponges had been rinsed out in sterilized water three times, the assistant cut off small pieces from each of the sponges to be used with scissors, and they were put in a tube of liquefied gelatin beef broth. This tube contains 3 such pieces of sponge surrounded by the clear solid gelatin. Out of 25 sponges from 7 operations, only a single sponge was found infected with a single colony. It appears that the sponges are sterile at the beginning of the operations, and if sterile, then, of course, aseptic. Five or six pieces of silk were usually taken from as many needles, and 1 inch cut off from each and put in a single tube of gelatin. More than 30 such pieces were examined from 9 operations, and not a single colony developed. In no case was the silk infected at the beginning of the operation. 3. Is the catgut sterile? (Schorse's carbolized catgut.) Several pieces at 4 operations were examined. In 1 case only did any colonies develop. In this tube you see 2 pieces of catgut at the bottom of the clear gelatin. Clinging to the side of one piece you can discover a small spheric white colony, and a little distance from it in the gelatin another similar colony. This catgut was from a new bottle of catgut used in operation 5 in a private house in the country. It is difficult to say how significant their presence is. They might arise from any one of the following causes: (1) Imperfect primary sterilization of the catgut. (2) Infection by floating germ or germs from the hands of the assistant when unwinding and cutting off pieces. (3) Infection through transportation to and from the country. (4) Imperfect sterilization of the nutrient medium. It is my own opinion that it is from infection through the second of the above-named causes. Thus, out of over 30 tubes containing over 60 pieces of material taken before the operations, only 2 pieces were found infected with 3 colonies. This would indicate that the precautions taken are very successful at the beginning of the operation. 4. Are sponges sterile after they have been used? At the end of each operation small pieces of each of the sponges used were cut off and placed in gelatin in the same manner as at the beginning. They were usually stained with blood, and sometimes had pieces of the contents of the cysts clinging to them. Thirty pieces from 8 operations were thus examined. In the tube which contains 2 pieces of sponge from the last operation, No. 8, are numerous colonies on the side of the upper sponge. They are spheric and whitish, and do not liquefy the gelatin. The following is the list of the sponges infected: Operation 1: 5 sponges examined; 1 infected. Operation 2: 2 sponges examined; 1 infected. Operation 5: 4 sponges examined; 1 infected. Operation 8: 2 sponges examined; 1 infected. The sponges were generally sterile at the close of the operation, even though most of them had come in contact with the skin of the abdomen and the contents of the cysts. It may seem strange that the sponges used in operation 4, pyosalpinx, in which the cyst burst into the abdomen in tearing it away from its adhesions, did not develop any colonies. Five sponges were examined, and all remained apparently sterile. From the pus in this cyst cultures were made in solid blood-serum with the growth of a small micrococcus, usually in the so-called diplococcus form, but this microbe would not grow in gelatin beef-tea. 5. Is the silk sterile at the close of the operation and after it has been used as sutures? Out of 20 pieces of silk, often cut from the ends of abdominal sutures, only a single piece was infected with a single coccus form, viz., one of the two pieces taken from operation 1. Over 50 pieces of material, after being used in operations, and only 5 pieces-4 sponges and 1 piece of silk-were found infected. It does seem, therefore, that the sponges and silk may be maintained sterile, so far as any germs that will grow in nutrient gelatin are concerned, even to the end of a long operation. In marked contrast to these results appear those from an operation performed by another operator who kindly allowed similar examinations. The details of the preparations were given for publication. The operating-room was well washed with soap and water-both walls and floor. It was in a new house which had never contained a sick person. The sponges were part new and part old, having been used in a previous abdominal section. After that operation they had been soaked a day in a strong solution of bicarbonate of soda, and washed out in a 5 per cent. solution of carbolic acid and hung away in a bag. On the day before the operation all the sponges were boiled in a porcelain kettle for more than an hour in a 2.5 per cent. solution of carbolic acid, and put into a jar and taken to the operating-room. The silk was boiled and carried in the same jar. The operator took a bath and put on perfectly clean clothes on the morning of the operation. The assistants were instructed to do the same. The hands and arms of the assistants were washed in soap and water and then in a sublimate solution 1:1000. The material examined consisted of 4 sponges and 2 pieces of silk before the operation, after the sponges were rinsed out, and the needles threaded, and of 2 sponges after the operation and several inches of the thread used. All the material was infected except one piece of silk examined at the beginning of the operation. Every sponge had at least one colony of the hay bacillus, and one sponge after use showed more than 50 small white colonies in the clear gelatin in the upper part of the tube. What influence the asepsis of the material has on the results of the operations as to death or recovery is a question far beyond the scope of these investigations. It would require a large statistical material of well-observed cases and more work than could be done by one observer. But it may be safe to conclude that it is desirable to work through an abdominal operation with perfect asepsis everywhere, if such a thing is possible. The above investigations have shown that such perfect asepsis can be attained. Thus, if we are ignorant of the extent of danger from non-sterile material, we are hardly justified in trusting to the innocence or innocuousness of such an uncertainty, while we can have the asepsis of the material an absolute guaranty against the dangers of infection. OPERATIONS PERFORMED BY DR. CHRISTIAN FENGER 1. Dermoid of ovary. Emergency Hospital, November 9, 1886. Bursting of cyst into the abdomen during operation; irrigation; 1 sponge and 1 piece of silk infected after operation; 4 tubes used to examine 12 pieces of material. Recovery. Development of properitoneal abscess, which was opened in the sixth week. Complete recovery. 2. Cystosarcoma of left ovary. Emergency Hospital, November 30, 1886. Solid movable tumor 6 inches in diameter, only slightly adherent to abdominal organs; metastasis in peritoneum; some ascites present. Drainage; 6 tubes used to examine 11 pieces of material; 1 sponge before use and 1 sponge after use infected, each with a single colony. Recovery. 3. Radical operation for hernia. Emergency Hospital, January 18, 1887. Eight tubes used to examine silk and sponges and catgut; all sterile. Recovery. 4. Pyosalpinx. Emergency Hospital, January 19, 1887. The sac, adhering on all sides, ruptured in removal. Irrigation of abdomen; 14 tubes of nutrient gelatin used; all sterile. Contents of cyst planted in solid human blood. Serum developed diplococci of very small size, which do not grow in gelatin, probably gonococci. Death from acute sepsis within forty-eight hours. 5. Double dermoid. Private house, January 24, 1887. The tumor of the left side had ruptured twenty years before, and produced an almost fatal peritonitis (?). This tumor was now large and adherent all around. The tumor on the right side was small and free; 9 tubes used with 25 pieces of material; 1 piece of catgut infected with 2 colonies; 1 sponge infected with a single colony. Death from shock within twelve hours. 6. Cyst of ovary. Emergency Hospital, February 3, 1887. Seven tubes used to examine 10 pieces of material; all sterile. Recovery. 7. Cyst of ovary. Emergency Hospital, March 22, 1887. Two tubes used to examine silk and sponges after operation only; all sterile. Recovery. 8. Malignant cyst of broad ligament. County Hospital, March, 1887. Four tubes used; all sterile. Death from uremia on the fifth day. Autopsy. Atrophic and dilated kidneys. 9. Proliferating cystoma of ovary. Emergency Hospital, March 24, 1887. Large and adherent; burst during removal. Irrigation of abdomen to remove cyst contents. Drainage; 5 tubes used, 12 pieces of material; only 1 sponge infected with numerous colonies. Death after thirty-six hours. Autopsy after six hours. Thrombosis of right ventricle. Bloody serum found in the peritoneal cavity in small quantity was added to nutrient gelatin. It remained sterile after two weeks' incubation. CONTRASTED CASE PERFORMED BY ANOTHER SURGEON IN WHICH LESS SUCCESSFUL ANTISEPTIC PRECAUTIONS WERE USED Cystosarcoma of ovary. Private house, February 22, 1887. Very large, and adherent to omentum and abdominal wall. Drainage by means of 2 rubber drainage-tubes; 9 tubes used for silk, and sponges all infected except one, containing silk, before the operation. The sponges, after use, contained many-50 to 100-colonies. Each of the 8 infected tubes had at least one colony of the háy bacillus. Death on the third day. No autopsy. At each daily dressing there was evidence of some oozing from the drainagetubes. A NEW COLPOPLASTIC OPERATION FOR ATRESIA OR DEFECT OF THE VAGINA* WHEN an atresia of the vagina, whether congenital or caused by inflammation or injury, is somewhat extensive, the common experience has been that, although dilatation, even up to full size, is usually comparatively easy, it is difficult to keep the newly formed canal from retracting; the constant use of the glass plug for this purpose is such an inconvenience that the patient will most often get tired of its use and leave it out, whereby the atresia will recur. Where the atresia is limited, forming, as it does, in some cases a thin perpendicular septum only, it requires but crucial incisions and a little subsequent dilatation. In such cases there is no difficulty, because there is mucous membrane enough to entirely cover the canal. But in extensive atresias, where mucous membrane is wanting, it is, so to speak, contrary to the laws of physiology that a canal formed by violence in uncovered connective tissue should not retract. When such a canal is not covered with skin or mucous membrane and not constantly kept open, either by mechanical appliances from without or a constant evacuation of secretion from within, there is nothing to prevent the canal from ceasing to exist as such. This is the law for fistulous canals all over the body, and must hold good for a newly formed canal in the place of the vagina as well. There are, however, many cases on record in which even extensive atresias of the vagina after gravidity have shown, at the time of delivery, a remarkable softening of the walls and dilatation, so as not to cause the expected impediment to the delivery of the child. It is not unlikely that the succulent and softened condition of the external genitals found toward the end of pregnancy is able not only to counteract the effects of the retraction, but even to permit of a certain permanency of cure. Breisky remarks, in this respect, as follows:† "The artificial dilatation of more extensive stenosis in non-pregnant women by means of sponge tents, dilators, and other mechanical means is usually partial and insufficient, and the success of only short duration. Amussat's operation of rapid dilatation with blunt instruments, as the handle of the scalpel and the fingers, is not any more efficient. The first to propose to obviate these difficulties was Heppner, of St. Petersburg, who, in 1872,‡ made the following proposal, when operat * Trans. Amer. Surg. Assoc., 1887, vol. v, p. 275. † Billroth and Lücke: Chirurgie, Die Krankheiten der Vagina, p. 57. |