Catgut, plain, sublimated, or chromated, has the great advantage that it is absorbed, so that it is not necessary to remove the sutures, but it is not any more readily disinfected, as Zweifel and Volkmann have proved, and it breaks so readily that we are obliged to use the larger sizes. For the purpose of the running, sunken suture, however, catgut is indispensable. I use silk almost entirely, and have left it for months in the tissues after plastic operations. Silver I rarely use for suture, but generally for controlling laminaria and tupelo tents.
The physician should pay most special attention to his own cleanli ness and to that of his assistants. The operator may be the carrier of in fection in the first place through personal disease, and in the second place in that infectious material from without clings to him. In the first category are to be ranked abscesses, boils, exanthemata, in particular erysipelas. For this reason, and also because when sick a man is not in full possession of his powers, operations should not be performed under the circumstances. The infectious material which may come from with out is incalculable. The most common sources are contact with patients suffering from gangrene, erysipelas, acute exanthemata, puerperal dis eases, suppurating tumors, and the dealings with cadavers or pathologi cal specimens. In case such diseases are among our patients it is advisa ble to postpone operations for a few days, as was Spiegelberg's teaching in labor cases. It is preferable to be too careful than not to be enough so. For my part I will not attend a labor case or operate on the same day that I have come in contact with anything infectious.
The source of contagion is, however, not always so evident; it is in ambush everywhere, even in the handshake of an unclean individual. Before every operation, therefore, a full hot bath should be taken; the hair, in particular the beard, is to be carefully washed, the teeth brushed (Mayrhofer wears a respirator). Immediately preceding operation the hands and forearms must be scrubbed with *soap and water, in particular the nails, which should be rubbed and scraped preferably with an ivory knife, since a steel instrument roughens them. The hands are then to be dipped in 5 per cent. carbolic, 1 per cent. thymol, 1 per cent. subli mate, permanganate of potass, after which latter it is requisite to place then in a dilute acid solution. Many operators are obliged to dispense with carbolic owing to the sensitiveness of their skin and the resulting eczema. During the operation a deep porcelain or glass vessel should be near the operator filled with disinfecting solution, in which he may occas ionally dip and rinse his hands.
The clothing may be carriers of infection. It should be completely changed before any major operation, and over it should be worn a long apron, of linen or, better, of rubber, reaching from the neck to the knee, and this apron should be carbolized freshly before use. The sleeves of
the operator's undergarments should be rolled up above the elbow. Gloves should never be worn, since they cannot be disinfected and may carry infectious material in their seams; further, the disinfecting action of the air and the light on the hands is desirable, as is proved by the readiness with which exposure to these agents rids the hands of odor.
The assistants must be as disinfected as the operator. No assistant, no visitor, should be allowed to be present at an operation who has on the same day come in contact with infectious diseases or cadavers. It is preferable to have an independent staff for assistance in aseptic operations. It is useful in case of many operations to have an assistant present whose sole duty it shall be to attend to certain matters, such as catheterization, the manipulation in the vagina during laparotomy, the pushing forward of the vaginal wall from the rectum in case of colporrhaphy, etc. The assistant who attends to the anesthesia should have nothing to do with the operation itself, seeing that he may not be completely aseptic owing to the patient's vomiting, etc.
An essential matter is the subjection of the patient to a course of disinfection. Since the majority of gynecological operations are not extremely urgent, we generally have one or two days in which to pre pare the patient, and on this preparation depends largely good convale scence and union per primam.
The patient should be carefully examined for the presence of infec tious affections. Ulcers, blennorrhea, etc., on other parts of the body should be treated beforehand. Before operation the body should be cleansed; the external genitals, in particular the parts covered with hair, should be scrubbed with soap and water, and the hair shaved from the parts which are to be operated upon. The field of operation must then be carefully disinfected with 2 to 3 per cent. carbolic solution, or sub limate. The abdomen should be covered with a carbolized compress before a laparotomy (Billroth), and only removed at the time. The vagina should be douched a number of times daily with some disinfect ing fluid, the patient occupying the dorsal position, and the thick mucus should be removed from the cervix. After the last douche I am in tho habit of having the vagina filled with carbolized glycerine tampons, or pre- • ferably with 50 per cent. iodoform gauze. The uterus should be washed oat through a double current catheter, and an iodoform pencil introduced into its cavity. In case an infectious growth, like cancer, is to be excised, then its surface is scraped with the curette and is cauterized in order to avoid infection of the wound at the time of operation.