(4) The Operation.—In addition to the proce dures necessary to fulfill the of the operation. the most painstaking care is exer cised to exclude all bacteria from wounds, in aseptic operations; and to kill or remove the bacteria present, and to avoid the introduction of more bacteria, in antiseptic operations. There fore, besides the elaborate preparations just de scribed during the progress of an aseptic opera tion. much attention must be paid to cleanliness. (a) No substance—finger, instrument, sponge, or dressing—is allowed to come into contact with the wound unless previously sterilized. (b) In struments, sponges, and the surgeons' and as sistants' hands are rinsed in. sterile solutions from time to time. (c) If, for any reason, hands o• instruments become soiled, they must be re sterilized before again coining into contact with the wound. (d) No antiseptic fluids are to be used in the wound. If any flushing at all is necessary, sterile salt solution only is allowable. For antiseptic operations, the same preparations are made, but here it is often advisable to use antiseptic rather than simple sterile solutions. Otherwise the precautions are the same.
The first step in so-called bloody operations is the division of the integument. This is done by cutting implements, as knives and scissors, or, sometimes, by the actual cautery, or the ecraseur. Subsequent steps are accomplished in a variety of ways: To expose deep-seated tissues, retractors arc used. To facilitate dissection, various forms of forceps are used. To puncture cavities, hol low needles and trocars are used. To scrape out tissue, sharp spoons are used. To divide hones, saws, chisels, and strong cutting forceps are used. The division of tissue involves more or less bleeding. To prevent bleeding, in operations upon the extremities digital or instrumental compression of the afferent arteries is prac ticed, or the afferent artery may be ligated as a preliminary step. During the progress of the operation the 'bleeding points'—ends of the ves sels—are seized by clamps, and then ligated with catgut. General oozing is controlled by packing the wound with dry gauze, or by flushing it with very hot salt solution, or by touching the surface with the actual cautery, or by elevating the part. At the end of the operation it re mains to treat the wound so as to secure healing in the shortest possible time, and with a mini mum scar, i.e. to secure union by first intention. For this purpose every obstacle to such union is removed. (a) Bleeding is absolutely stopped. (b) Foreign bodies, including bacteria. are re
moved. (c) The walls of the wound are brought into close contact and no 'dead spaces' allowed to remain. (d) Drainage is provided for, i.e. vents established for the escape of wound secre tions. (e) The wound is protected from possible bacterial invasion, and the wounded tissues sup ported and immobilized by dressings.
(5) After-MT/Lb/it-O.—After the dressing has been applied, the patient is moved to his bed and allowed to recover from the Mor phine is often given to diminish vomiting and to mitigate anticipated pain. General symptoms, as shock or acute anemia, are treated if they exist. No food or drink is given by the mouth until the nausea and vomiting caused by the anaesthetic have ceased. Then small but increas ing quantities of milk or beef-juice are given until the desired diet is taken. If there is reten tion of urine, the bladder is emptied with the catheter. The bowels are to be moved by the sec ond or third day after operation. Drains are removed in two to five days. Sutures are re moved in five to seven days. If suppuration, due of course to bacteria, develops, the particular inflammation excited is to be treated as indicated by its characteristics.
From what has just been outlined it is obvious enough that all of the conditions looking toward the successful issue of a serious operation can be secured only in hospitals of first-class equip ment; and it is to be noted that this fact is be coming so generally' known that hospitals of the first class are being established and operated not only in the larger cities of this country, but also in the smaller ones and even in villages. Insti tutions of this kind are of benefit to the com munities in which they exist and by which they are supported in many ways. Tbey furnish at a nominal cost, or very often without charge, care for the sick poor that could be supplied in no other way; and the well-to-do may find in them facilities for the treatment of disease and par ticularly for the conduct of operations that can not be secured even in their own homes. For the community at large they are also of the greatest value, since they afford for the medical men who serve in the hospitals a field which amplifies their experience indefinitely. Again, in the larger cities where medicine is taught as before out lined the hospitals may be regarded as parts of the laboratory system. The wards are the places in which the student finally gains his practical experience in the recognition of particu lar disease forms and the treatment of them.