FIG. 190.-View of the sterilizing and operating rooms of the Gynecean Hospital, Philadelphia. The apparatus is arranged for operation. A, flasks of sterile water; B, jar containing silk ligatures in glass tubes; C, instrument-sterilizer containing boiling water; D, tray containing sterile water for instruments at operation: E, basin for washing sponges; F, basin for washing hands of operator during operation; G, tray for sutures, ligatures, and needles; H, jar of cold sterile water; /, kettle of hot sterile water; K, water-sterilizer; L, dressing-sterilizer.

bath and change all clothing. Care in this respect is especially desirable on the part of the nurses, whose long hair prevents easy cleansing of the head.

The operator and assistants should wear sterilized outer clothes-cotton shirt and duck trousers. A large sterilized apron put on immediately before the operation is an additional protection. The nurses should wear large sterilized aprons over freshly washed, if not sterilized, dresses.

The hands and forearms of the operator, assistants, and nurses should be bare and especially sterilized. The finger-nails should be short, rounded, and smooth. A long nail is difficult to clean, and in the case of the operator is dangerous, as it may lacerate important structures in the process of enucleation of a tumor. Enucleation of adherent growths is best done with the blunt finger, which passes along the planes of separation. The sharp nail may perforate an intestine or lacerate a blood-vessel, instead of pushing it aside.

The nails, fingers, hands, forearms, and lower part of the upper arms should be thoroughly scrubbed with frequently changed hot water and soap (preferably soft soap) and a large stiff nail-brush. The process should not be done hastily or but once. The soap should be repeatedly washed off and renewed. Five minutes, at least, should be devoted to the scrubbing. The hands and arms should then be similarly scrubbed with alcohol, and finally scrubbed with a solution of bichloride of mercury I: 1000. Immediately before proceeding with the operation the hands and arms should be rinsed in sterile water.

There should be a nail-brush for each solution used. The brushes should be clean and sterilized by boiling. or by placing in the steam sterilizer.

After sterilizing the hands, the operator, the assistants, and nurses should touch nothing which is not sterile. If they are obliged to do so, the hands should be again washed.

Sterilization of Dressings, Towels, etc.-The ope

rating-cloths, aprons, sheets, towels, dressings, gauze pads, etc. are most conveniently sterilized by steam heat. The temperature should be at least 100° C. (212° F.). The dressings and bandages should not be too tightly packed, so that all parts may be exposed to the same temperature.

Several kinds of steam sterilizers have been introduced. The most easily obtained is the Arnold sterilizer. An apparatus like the Sprague sterilizer, in which the steam is superheated, is preferable, but, as it is not portable, it is adapted only for hospital use.

The dressings should be maintained at the elevated temperature for an hour or more. Although this method secures very good sterilization, yet there are certain spores which resist such elevated temperature even after a two hours' exposure. The method of fractional or discontinuous sterilization has therefore been introduced. Two or three successive sterilizations are practised at intervals of twenty-four hours. Spores which at first escape destruction will have developed into vegetative forms in the intervals, and are destroyed by the final sterili

zations.

At the University Hospital all dressings are sterilized for three consecutive days for two hours each day. The dressings, towels, etc., after sterilization, should be preserved in sterile glass jars or other sterile receptacle.

Sterilization of Instruments.-Instruments, drainage-tubes, catheters, and any rubber appliance may be sterilized by boiling in water for fifteen to thirty min utes. A dilute solution (1 per cent.) of carbonate of soda is preferable, as the instruments are not so easily rusted, and this solution, when boiling, has greater germicidal qualities than plain water.

Very convenient instrument-sterilizers are made, in which the instruments are contained in a tray that may be lifted out and placed in the receptacle for containing the instruments during the operation. This receptacle or pan should itself be sterilized, and should contain sterile

multiple of this number, of sponges has been used. The writer uses such sets of seven gauze sponges of the following sizes: one sponge 3 by 3 inches; one sponge 10 by 7 inches; five sponges 5 by 5 inches. Usually one such set of sponges is enough for an abdominal operation. In some cases, however, the first set of sponges may become soiled by the discharge from an abscess or a suppurating tumor, and it is advisable to discard these sponges and to complete the operation with a second

clean set.

The number of sponges should never be altered during an operation by cutting one in two.

Sponges should never be removed from the operatingroom until the abdomen has been closed and the sponges have been counted. If a sponge falls on the floor or in the vessel to receive slops, it should be put aside until the final counting is completed.

When a set of sponges is used, they should always be carefully counted as they are placed in the basin, for the nurse who prepared and put up the set may have carelessly miscounted them.

Accuracy in regard to the sponges is of the greatest importance. There are a number of recorded cases, and many unrecorded, in which sponges have been left in the abdomen. This accident is usually fatal, though there are several cases on record in which the sponge has made its way, by ulceration, into the intestine, and has been discharged from the anus, or has been removed by subsequent incision through the abdominal wall.

Discipline of the Operating-room.-The discipline of the operating-room should be most rigid. Perfect personal asepsis can be obtained only by continuous watching and criticism. The work should be systematically divided among the assistants and nurses, and each should attend strictly to his or her own department, and to nothing else.

The first assistant should assist the operator with sponges, etc. The second assistant should attend to the

instruments, ligatures, and sutures. The first nurse should wash the sponges and place them in a basin of sterile water beside the first assistant. She should also attend to the towels and dressings. The second nurse, under direction of the first, should change soiled water in the sponge- and hand-basins, etc.

No one should pick up anything that may have been dropped upon the floor, and no one, unless it is absolutely necessary, should touch anything that has not been sterilized.

Anesthesia. With the exception of the operator, the anesthetizer is the most important person at an abdominal operation. A careful, experienced anesthetizer is desirable in all operations, but especially so in an abdominal operation. Much more depends upon him than upon the assistant. The custom of trusting the anesthesia to the least experienced man is reprehensible. Many fatal cases after celiotomy may be attributed directly to the anesthesia.

Every operator of experience has observed the difference in reaction between those patients who have been carefully anesthetized and those who have been improperly anesthetized. In a serious case attended by unavoidable shock the superadded depression of ether-poisoning may be enough to cause a fatal result.

The operator should have nothing to do with the anesthesia, and it should not be necessary for him to watch it. The anesthetizer should make a careful examination of the heart, and should be provided with a hypodermic syringe and the necessary stimulants, which he should. use at his own discretion.

He should, of course, use the minimum amount of ether. He should be familiar with the steps of the operation, and he should so regulate the anesthesia that the operator will not be impeded by the straining or struggles of the patient at critical moments.

Preparation of the Patient.-It is always desirable, when possible, to have the patient under observation for