The use of sublimate in gynecology is hence limited, but in obstetrics it finds its full place, although we must not forget the possibility of toxic effects. The solution is kept ready for use by making a 5 per cent.
solution of sublimate in alcohol, and adding a sufficient amount of this to a quart of water to make .5 per cent. to 1 per cent. solutions.
In gynecology, where generally we deal with wounded surfaces in cavities, iodoform is the best antiseptic. Since its recommendation by Billroth and Mosetig I have used the drug frequently as a dressing, and I have found it a most valuable agent in the aseptic treatment of injuries to the uterus.
After the appearance of Mosetig's article, many authorities at once spoke in its favor, for instance, Rehm, Billroth, Demarquay, Fritsch, Friihwald, Kouig, Leisrinck, Martin, Mikulicz, Neuber, Nussbaum, Sanger, Schficking, and others. The typical Lister dressing was dis pensed with in great measure, and the wounded surfaces were either covered with pulverized iodoform, or with gauze impregnated with the drug. The great enthusiasm in its favor, however, has been chocked by the observance of toxic cases. The temperature rises, although the wound is healthy, the pulse increases in frequency, the intellect is clouded, in extreme cases there is collapse, acute delirium, deep coma, speedy fatal termination. Schede, Kunig, Kocher, Mikulicz, Goldschmidt, and others, have reported such cases of poisoning; Konig, in 1882, found thirty-two reported instances; in the same year Kocher collected twenty three, and for this reason gave up the drug and substituted sub-nitrate of bismuth in its place. Many authorities, however, notwithstanding the danger of poisoning, will not dispense with it. In 1882 Mosetig in 7000 cases had no instance of poisoning. He cautions against the simultaneous use of carbolic, seeing that it may cause kidney inflammatory troubles, which may prevent the elimination of the iodoform. For the past five years I have used iodoform and iodoform gauze, and only once, after an intrauterine application of 150 grains, did I notice slight affection of the sensorium.
Even from the use of small quantities of iodoform toxic symptoms have been observed, but in general the chances of poisoning arc in direct relation with the amount used, and iodoform gauze carries with it less risk than the powder. It goes without saying that on the slightest symptom of toxicity the drug should be intermitted, and whatever is on the wounded surface should at once be removed.
Iodoform is applied in powdered form by means of an insuffiator, of which there are many forms, or else in the form of the ether-iodoform spray. In the uterus it is preferable to use iodoform pencils. Cavities are best filled with iodoform gauze. The opinion that it is not possible to bring iodoform into contact with the entire endometrinm does not seem to me to be well founded. The drug is disseminated by the uterine mus cular activity. Latterly, in a case of retention of a placental remnant, after two intrauterine injections I inserted each time sixty grains of iodoform, and when the remnant was removed it was saturated with the drug even as would be a sponge.
A stringent objection to iodoform is that it does not suffice for over coming sepsis. This is valid in that it possesses no caustic effect, and in essential cases it must yield to other antiseptics and to caustics. As a prophylactic agent, however, I must rank iodoform above all others. Since the introduction of iodoform-tannin gauze, further, we possess in addition to disinfectant an hemostatic effect.
A sine• non in the prophylaxis of septic diseases is the prevention of hemorrhage. This is aimed at by the use of the tampon, caustics, cautery, ligature, suture. Wherever possible we should endeavor to obtain union by first intention, and here is the indication for the suture. Only when necessary for checking hemorrhage should we use the ligature, the cautery, or the tampon associated with styptics.
The simpler the suture the less likely it is to irritate the united edges, and the better the adaptation the more likely primary union. The various complicated methods of suture formerly in vogue are, rarely used now-a-days, but generally the surgeons' knot, or the running suture for quick adaptation. As to whether silk or wire be used varies according to the preference of the individual operator. It is of much more importance to include tissues of sufficient vitality in the sutures, and to obtain parallel and even adaptation. Generally deep sutures are inserted, and between them superficial. Ragged edges, blood clots, should be removed before tying the sutures. The sutures must not be tied too tightly, but suffici ently to prevent the interposition of blood or fluid between the edges. If after the introduction of the sutures there is hemorrhage, then a suture must be passed under the vessel or it must be tied.