Curt Schimmelbusch.

A guide to the aseptic treatment of wounds online

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FIG. l8. FIG. 19.

CLOSABLE BOX IN WHICH DRESSINGS DRESSING BOX ENCLOSED

ARE STERILIZED IN STEAM. IN A LEATHER CASE.

bands. The dressings, ready for use, are placed in the receptacles, and, with
the perforations open, these are set into the sterilizer. Steam is developed
so forcibly that the entire chamber is filled in a quarter of an hour, unless the
contents are firmly packed. The dressings are only slightly saturated, hav-
ing been thoroughly warmed previously. If the receptacles are allowed to
stand for a short time after removal, uncovered and with perforations open,
the dressings become perfectly dry. The bands are then closed over the
orifices, and the cover is replaced. In private surgical practice these boxes
may be carried about in a leather case (Fig. 19).

The time required for an exact sterilization of the dressings, if the latter
are not compressed so as to offer special resistance, is thirty minutes, after
the apparatus is filled with steam. The filling of the boiler with steam.



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A SEP TIC DRESSING MA TERIALS. 1 05

depends upon its capacity and the efficiency of the heat supply. In Lau-
tenschlager's sterilizer the time as stated, is fifteen minutes from the
moment the steam begins to develop, until the chamber is completely filled.
As soon after application of heat as is indicated by active boiling cf the
water and the development of steam, the dressings are set into the chamber,
and after three quarters of an hour they may be removed as reliably sterile.

The various sterilizing devices of Schimmelbusch detailed
in the foregoing chapters are admirable in their purpose and
execution. It appears, however, that an additional feature
might be incorporated in a combination sterilizer : that of
asepticizing simultaneously water. The translator accord-
ingly introduces the following design which is intended to
meet the requirements of the general practitioner as well as
the specialist in surgery,' obstetrics, and gynaecology.

As shown in Fig. 21 it consists of a boiler {B) in which the water is steril-
ized, a tray (C7) containing soda solution in which the instruments are steril-
ized, and an upper chamber {E) for sterilizing the dressings.

The steam for the latter is generated in a jacket of water {A)^ which
envelops the lower boiler and upper instrument tray. The dressing chamber
is provided with double walls separated by a narrow space which corresponds
. to the outer water compartment below, the communication between the two
being direct. Through the upper intervening space steam ascends from the
water jacket to enter, through a line of perforations, the inner chamber at
the top. Hot air passes up around the dressings through the outermost space
(AO, so they are warmed before the steam encounters them. The water
jacket extends from the bottom of the water boiler on all sides upward to the
top of the instrument tray. It has drain ( /) and inlet pipe {G) attached. The
inner walls of the water jacket form the walls of the boiler for sterilized
water on four sides and below. Resting into the boiler above is the shallow
instrument tray with soda solution. Above the tray is the chamber for
dressings.

In the latter are contained two sub-compartments (F F) — small closed
boxes — with two rows of perforations in the top and bottom, left open for
entrance of steam while the dressings are sterilizing, afterward closable to
preserve them uncontaminated. The steam, after permeating and traversing



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I06 A GUIDE TO ASEPTIC WOUND TREATMENT.

the dressings — gauze, cotton, bandages, etc. — contained in the boxes in the
upper chamber, escapes through a vapor pipe at the side into the open air,
or may, in case of an apparatus of large proportions, be conducted through
a coil of pipe and condensed in a vessel of cold water.

Supply and drain pipes are provided to the water boiler so that it may be
filled, or sterilized water drawn off, as desired.

The whole apparatus is closed at the top by a tightly fitting cover which
sits into a water seal around the periphery.



FIG. 20.

COMBINATION STERILIZER FOR WATER, INSTRUMENTS, AND
DRESSINGS (THORNBURY).



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ASEPTIC DRESSING MATERIALS,



107



A thermometer for registering the temperature in the steam chamber pro-
jects through the cover in the centre as shown in Fig. 20. The temperature
here and in the boiling water will be found to be uniformly loo** C and about
104** C in the soda solution. The apparatus is heated by means of a gas
pipe ( y) running underneath and containing a number of jets so that the
heat may be distributed over as great an extent of surface as possible. The
alcohol lamp may also be used for heating. Owing to the compactness of
the apparatus, its comparatively small size, and the provision for rapid heat-
ing in use of gas, the entire sterilizing process occupies but a short time.




FIG. 21.

COMBINATION STERILIZER (THORNBURY).

Vertical Section.

A^ water jacket ; B. water boiler ; ^ C, soda tray • />, instrument tray ; £^ upper steam
chamber • ^, ooxes for dressings ; G^ supply pipe to jacket ; /r, tap^ to sterilized
water boiler ; /, faucet to water jacket ; 7, gas supply pipe ; A', hot-air chamber.

The water and soda are boiled in three to five minutes — the instruments
sterilizing in the soda, — the upper chamber is filled with steam in twelve
minutes, and in twenty-eight minutes the dressings are sterilized.

Two boxes of dressings may be asepticized at one time, and in the inter-
vals a quantity sufficiently large to last for a number of operations, so that,
in case of emergency and want of time, only a delay of about ten minutes is
occasioned. This short time for sterilizing the instruments and water may
occupy the interval of details preliminary to the operation.

The dressings, after having been asepticized, are removed in the small boxes
(no secondary handling and contamination being permitted) and allowed to
dry out, although there has not been much saturation through condensation.



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I08 A GUIDE TO ASEPTIC WOUND TREATMENT.

owing to the dressings having been warm before the steam encounters them.
They sit directly over and rest upon a tray of hot soda solution ; besides the
steam is generated rapidly, is saturated and under considerable tension, and
consequently has not much tendency to condense on the articles.



FIG. 22.

THORNBURY STERILIZER.

Af main body of apparatus ; B, water seal ; C, soda reservoir removed ; D, instrument
tray with contents, removed ; £, sub-compartment for gauze, cotton, bandages, etc.,
dighdy elevated ; F^ dressing box No. 2 removed, cover raised ; G, steam chamber
which contains dressing boxes ; H, water jacket ! I, supply pipe to water jacket;
J, outlet to jacket ; K, tap to sterilized water boiler ; L., gas-pipe ; M, hot-air
interspace.



To cause evaporation of any moisture that may have occurred, and dry
thoroughly the dressings so they may be preserved for future use, hot air may



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ASEPTIC DRESSING MATERIALS. I09

be passed through them in a manner to be hereafter described. The dress-
ings having been sterilized and dried, keep aseptic indefinitely in the tightly
closed boxes. The latter are readily transportable, so the surgeon may have
sterilized gauze constantly at hand in his private practice. In using this
combination sterilizer, first the boiler is filled with water ; second, a one-per-
cent, soda solution is placed in the tray, and in the latter the instruments are
submerged in a shallow wire basket (Z>). Next the boxes are filled with
dressings (leaving the cover and bottom orifices open) and set into the steril-
izing chamber. Water is now allowed to flow from the hydrant to fill the
jacket, and then the gas is turned on, or the alcohol lamp adjusted. After
the sterilizing process is completed the water is drawn from the jacket through
a faucet at the side, and water from the hydrant is allowed to course through
around the sterilized water in the boiler, cooling it for immediate use. The
instruments have been sterilized in the soda which has boiled, and are now
taken out and set into a tray containing a cold solution of carbolic acid and
soda. The gas or alcohol flame allowed to continue generates dry heat (the
jacket being empty), which takes the same course to dry the dressings as the
steam did in sterilizing them. This constitutes the apparatus and its working
complete.

It is made in two styles. No. i entirely of tin ; No. 2 of copper with
Russian iron cover.

The dimensions are : length, 17 in. ; width, 13 in. ; height, 18 in.

The third requirement of a dressing is that it shall work
antiseptically and prevent as far as possible the development
of bacteria in the wound secretions. This is particularly im-
portant where we have to deal with wounds already infected,
but is none the less applicable to those which are recent and
have occurred under aseptic circumstances. The wound secre-
tion is such an excellent culture medium for low organisms,
that individual bacteria which gain entrance to saturated
dressings would multiply to an enormous extent, if there were
no special influence to antagonize them.

It was formerly supposed that an antiseptic property might
with great certainty be imparted to the dressings by impregnat-
ing them with antiseptics. The materials prior to use were



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no A GUIDE TO ASEPTIC WOUND TREATMENT.

dipped into a germicidal solution, and then either wet or pressed
out were applied to the wound ; or else they were used dry
after the impregnation, and the secretions were required to
re-dissolve the antiseptic thus suspended. The trials which
have been made with the various antiseptic agents in this way
are very numerous.

In later years we have become convinced that through a cer-
tain property in dressings, viz., dryness, there is imparted more
anti-microbic influence than by all antiseptics with which we
have thus far experimented. There is no means which, in so
simple, non-injurious, and at the same time more efficacious
manner, prevents decomposition of the wound secretions in
dressings — the evaporation of the coagulated products of secre- ,
tion. Moisture is the essential living constituent of low organ-
isms ; dryness is the germ's greatest enemy. Remove from a
bacteria culture medium its contained moisture and growth of
the organisms ceases. If we provide in our occlusive dressings
for drying out of blood, pus, and wound secretions we prevent
the development of germs. It is the meritorious work of the
Esmarch school, especially of Neuber, to have placed in its
present light the importance of dry dressings.

Schlange, in the von Bergmann Clinic demonstrated by ex-
periments how promptly dryness works against every form of
germ life. He saturated layers of gauze with aqueous extract
of beef or nutrient bouillon and inoculated the upper surface
with the green pus bacillus. The layers of gauze thus inocu-
lated were placed on glass plates, and some of the latter were
left open so that evaporation of the fluid could take place. It
was here observed that growth of the micro-organisms was very
limited. Other plates of the same series were covered to pre-
vent evaporation, and the bacilli proliferated luxuriantly, giving
rise in a short time to their characteristic green color and
growing through the entire thickness of the gauze. Again,



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A SEP TIC DRESSING MA TERIALS. 1 1 1

when evaporation was allowed to take place after the organisms
had permeated the gauze for a few centimetres, the area of
extension of the bacilli became overrun in a short time by the
rapid advancement of the dried zone in the nutrient media, and
further vegetation ceased.

In order to facilitate the drying out of the dressings, the
proper material must be selected and so applied that evapora-
tion of the secretions is in no way interfered with. Gauze and
moss are to be preferred, as they not only absorb large quanti-
ties of discharge, but have the property of permitting rapid
evaporation of the watery constituents in the absorbed secre-
tions. The interlaying, or external application of layers of
impermeable material over the surface of the gauze, is contra-
indicated.

Dryness is vastly superior to the use of impregnation with
antiseptic solutions, as it counteracts germ development without
damaging the tissues of the body. The application of antisep-
tics in dressings is always a remedium anceps ; a weak solution
does not prevent the germs from multiplying, while a strong
solution proves doubly dangerous, as it has a destructive influ-
ence upon the tissues of the body as well as upon the germs.
It is not necessary to have presented at once a general intoxi-
cation ; the local effect is often sufficiently manifest and trou-
blesome. There frequently occur under the impregnated
dressing symptoms of intense irritation, and increased secre-
tions together with cutaneous eczema place in question the
propriety of the whole antiseptic treatment. We have to con-
sider, not only a certain amount of idiosyncrasy to the antisep-
tics contained in dressings, but also the susceptibility to the
effect of the chemicals used in disinfecting the skin preparatory
to operation. The value of antiseptics in dressings has been
over-estimated. We must recognize that it is not in water or
bouillon that we have the development of bacteria to prevent.



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112 A GUIDE TO ASEPTIC WOUND TREATMENT.

but rather in rich, nutrient, albuminous substrata, which it is
true do not absolutely neutralize the applied agents, but do
markedly reduce their efficiency. The layers of dressing
immediately covering the wound are rapidly washed out by the
secretions which are poured forth, and are thereby rendered
valueless.

It is difficult to maintain a continued and uniform quantity
of antiseptic substance in impregnated dressing materials.
The chemicals undergo decomposition after long intervals, not
only in the dressings covering the wound, but also in dry and
cautiously preserved packages. Carbolic acid evaporates, and
corrosive sublimate enters into ineffectual combinations. Con-
sequently packages of cotton and sublimated gauze, after pres-
ervation for from one to two years, contain only insignificant
traces of the original abundant supply of bichloride. A good
impregnation can only be accomplished by the use of resinous,
oleaginous substances or glycerine, because the antiseptic
without these, does not remain in suspension, but precipitates
upon drying. Such combinations vitiate the absorptive power
of the dressing materials, however, thereby depriving them of a
property the importance of which we have just made explicit.

In the von Bergmann Clinic all wounds in which the drying
out of the dressing could possibly be achieved, have for years
been treated with a sterilized and good absorbing article —
gauze or moss, the use of impregnation being entirely dis-
pensed with. Moist dressings covered with impermeable layers
of oiled paper or guttapercha are avoided, as they facilitate
materially the development of bacteria in the wound's secre-
tions. Such dressings cannot be allowed to remain for more
than twenty-four hours in suppurating wounds without giving
rise to a perceptible, foul odor. In only two instances is the
favorable working of the dry dressing of wounds inapplicable :
first, where we have to deal with a tenacious, thick or, perhaps



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A SEP TIC DRESSING MA TERIALS. 1 1 3

ichorous discharge ; second, in the tamponing of wound
cavities.

The tenacious secretions are absorbed with difficulty by
even gauze and stagnate under the dressing, so that, used in
tamponing wound cavities, a drying out from the depths can-
not take place. Here the requirements for an antiseptic ma-
terial inserts itself for the immediate covering of the wound,
while for the outer layers, as before, evaporation remains
worthy of effort.

For imparting an antiseptic property in case of the wound
tampon, neither sublimate, carbolic acid, nor salicylic acid are
adapted, but no remedy better than iodoform. Uninfluenced
by the numerous attacks made against its use in the past few
years, this remedy maintains its place in the list of dressing
agents, and is to the surgeon indispensable, even though from
a bacteriological standpoint its efficiency has been placed
much in question. No other agent prevents with such cer-
tainty the decomposition of wound secretions in tampons, and
at the same time works so slightly irritant and toxic. But
the iodoform dressing should not be made by saturating the
gauze with an ethereal solution or glycerine emulsion. In pres-
ence of the former, the iodoform decomposes readily, libera-
ting iodine, while the latter impairs the power of absorption.
The better way is to simply powder the iodoform into the gauze.
Unfortunately gauze thus made cannot be sterilized in steam
as the iodoform is thus destroyed.

In the von Bergmann Clinic this dressing is prepared by

sprinkling sterilized gauze with boiled water, then distributing

iodoform over it, rubbing it in with a small sterilized pledget,

and then ironing the gauze with a sterilized compress, after

which the material is preserved in a sterilized receptacle. For

ordinary occasions it is better to simply rub the iodoform into

the gauze shortly before using it. In wounds with a foul,
8



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114 ^ GUIDE TO ASEPTIC WOUND TREATMENT.

tenacious discharge, instead of iodoform, oxalic acid, oxide
or chloride of zinc, may be used to advantage. The better
application is a combination of acetate of aluminum 3 ^,
with chloride of zinc in a i ^ aqueous solution ; the gauze is
dipped into this solution and is then pressed out thoroughly
and laid in thin layers over the wound. Impermeable ma-
terials are also omitted in this dressing, and layers of gauze
and moss used for external covering.




FIG. 23.

GLASS COMPRESS.

Although from an aseptic standpoint, and by reason- of
cheapness, the personal preparation of sterilized articles of
dressing is superior to the use of impregnated and asepticized
factory supplies, the latter cannot be entirely dispensed with.
In case of emergency, for instance, where aseptic material
must be in readiness, and where neither time nor circum-
stances permit of a sterilizing apparatus being used, dressings
thus provided have their full range of propriety. But sur-
geons who strive to have their results infallible will conduct
the sterilization of their own dressings, or assign the work to
a skilled assistant.

The proper wrapping of packages of dressings prepared by
manufacturers is a very important matter. Sheet-iron boxes
or cases afford a very excellent safeguard against saturation
of any part of the package, and a subsequent liability to the
development of organisms. But usually the simple paper^
pasteboard, or parchment covering will answer. The pack-"
ages must be sterilized after they are filled with dressings cut



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A SEP TIC DRESSING MA TERIALS, 1 1 5

of the proper dimensions, so that asepsis of the wrappers as
well as the contents is insured. The closure of the package
must be effected without the contained articles being dis-
turbed. These different requirements are easily met in
various ways.



FIG. 24.
lee's glass box jars containing aseptic gauze.

translator's note.
In this country one of the most reliable sources of aseptic surgical sup-
plies is the J. Ellwood Lee Co., of Conshohocken, Pa. I have taken occa-
sion to investigate the methods employed by this firm, and have noticed
the quality of their products. I therefore have no hesitation in expressing
an opinion with reference to the latter. The daily capacity of the firm is
13,000 yards of gauze, put up in various forms. The work is conducted as
follows : First the gauze is bleached, it is then washed thoroughly in boiling
water, after which it is submerged for some time in very hot water. Next >it
is run through a drying machine, and wound upon sterilized rollers. The
entire process takes place automatically, and the materials are not encoun-



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Il6 A GUIDE TO ASEPTIC WOUND TREATMENT

tered by the hands of any employee. After the packages are wrapped, they
are re-sterilized in steam. One form of package, which is very popular, is a
small air-tight box or "carton," containing five yards of aseptic gauze.
After being sealed, these packages are placed in boiling paraffin, and a
waxy coating applied, which is increased in thickness by repeated submer-
sions. One such package serves for a single large surgical dressing, and nu
gauze is left over to become contaminated after the parcel is broken.
Another form of package prepared by J. £11 wood Lee is the glass box jar
shown in Fig. 24. This contains five yards of aseptic gauze, and is air-tight.
After the box has once been opened and part of the material used, the
remainder may be re-sterilized by placing the box in boiling water or steam.
The gauze may be withdrawn without removing the roll as indicated in the
illustration.

This jar is of convenient size, and may answer several useful purposes after
its contents have been exhausted.

The firm referred to also manufacture five-yard hermetically sealed *' car-
tons" of iodoform gauze (10 $), which is reliable.

I simply mention these latter products for the benefit of those who through
emergency or other circumstance may not be in position to sterilize their
dressings. This will often be the case with practising physicians who do a
limited amount of surgical work.



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CHAPTER VIII.

ASEPTIC SUTURES AND LIGATURES.

Non-Absorbable Material : Silk and Wire Sutures — Absorbable Material :
Catgut — Disinfection of Silk by Boiling — ^Von Bergmann's Method of
Sterilizing Silk in Steam — Advantages of the Same — Linen as a Suture
Material — Sterilization of Wire Sutures — Sterilization of Catgut — Lister's
Original Method — Kocher's Juniper-Catgut — Von Bergmann's Sublimate
Catgut — Hot-Air Sterilization of Catgut — Disinfection in Xylol according
to Brunner — Advantage of the Corrosive-Sublimate Treatment of von
Be]^;mann — The Process of Absorption in the Body and its Duration.

A VARIETY of materials was recommended and used in the
pre-antiseptic period for suturing and ligaturing.

Surgeons formerly endeavored to close vessels and wounds
by means of sutures without obtaining a reaction. Unfamiliar
with the true cause of suppuration and inflammation, but con-
jecturing that the secret of the results lay in the suturing ma-
terial used, they always sought after a new article.

Now we know that neither the material, its color, coarse-
ness or fineness have any influence whatever, but that the
absence of reaction during repair is dependent on the asepsis
of the material employed. Individuals come to acquiesce in
the use of a reasonably reliable article, and to direct their
efforts toward disinfecting the same with the greatest possible
thoroughness.

To-day we use materials which are :

I. Designed to gradually undergo liquefaction in the tissues
and subsequent absorption : absorbable materials ; and

117



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Il8 A GUIDE TO ASEPTIC WOUND TREATMENT,

2. Articles which are to become permanently imbedded in
the tissues, or which are removed after a certain time : non-
absorbable materials.

By absorbable ligature, catgut is understood ; while as non-
absorbable, only silk and wire properly come under considera-
tion.

The sterilization of silk is not a difficult task. But it is not
sufficient, as many formerly supposed, to dip the threads for
a few minutes into a disinfecting solution, unless we apply 5
per cent, carbolic acid or i per cent, corrosive sublimate ;
pathogenic spores, and also bacilli and cocci, which are im-
bedded in layers of fat, albumen, or dirt, may retain their
virulence in such solutions for days, and even weeks. Also
the impregnation of sutures with antiseptics dissolved in oil
or fatty substances should no longer be practised, since Koch
has established that antiseptics thus applied suffer almost a
complete loss of their germicidal properties. The old English
method of preparing silk ligature — the saturation of the ma-
terial with a mixture of carbolic acid and liquefied wax (1:9)
— has, with propriety, become universally obsolete.

For the sterilization of silk, heat is best adapted, and may


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Online LibraryCurt SchimmelbuschA guide to the aseptic treatment of wounds → online text (page 9 of 19)