THE 
RELATION OF BACTERIA 
TO 
PRACTICAL SURGERY. 
THE ADDRESS IN SURGERY 
THE MEDICAL SOCIETY OF THE STATE OF PENNSYLVANIA, 
DELIVERED BEFORE 
June 4, 1890. 
BY 
JOHN B. ROBERTS, A.M., M.D., 
PROFESSOR OF SURGERY IN THE WOMAN’S MEDICAL COLLEGE, AND IN THE 
PHILADELPHIA POLYCLINIC. THE 
RELATION OF BACTERIA 
TO 
PRACTICAL SURGERY. 
THE ADDRESS IN SURGERY 
DELIVERED BEFORE 
THE MEDICAL SOCIETY OF THE STATE OF PENNSYLVANIA, 
June 4,1890. 
BY 
JOHN B. ROBERTS, A.M., M.D., 
PROFESSOR OF SURGERY IN THE WOMAN’S MEDICAL COLLEGE, AND IN THE 
PHILADELPHIA POLYCLINIC. 
PHILADELPHIA: 
WM. J. DORNAN, PRINTER. 
1890. ADDRESS IN SURGERY. 
JOHN B. ROBERTS, M.D., 
OF PHILADELPHIA. 
The revolution which has occurred in practical surgery since 
the discovery of the relation of microorganisms to the compli- 
cations occurring in wounds has caused me to select this 
subject for discussion. Although many of my hearers are 
familiar with the germ theory of disease, it is possible that it 
may interest some of them to have put before them in a short 
address a few points in bacteriology which are of value to 
the practical surgeon. 
It must he remembered that the groups of symptoms which 
were formerly classed under the heads “ inflammatory fever,” 
•‘symptomatic fever,” “ traumatic fever,” “ hectic fever,” and 
similar terms, varying in name with the surgeon speaking of 
them, or with the location of the disease, are now known to 
he due to the invasion of the wound by microscopic plants. 
These bacteria, after entering the blood-current at the wound, 
multiply with such prodigious rapidity that the whole system 
gives evidence of their existence. Suppuration of wounds is 
undoubtedly due to these organisms, as is tubercular disease, 
whether of surgical or medical character. Tetanus, erysipelas, 
and many other surgical conditions have been almost proved 
to be the result of infection by similar microscopic plants,' 
which, though acting in the same way, have various forms 
and life-histories. 
A distinction must be made between the “ yeast-plants,” 
one of which produces thrush, and the “ mould-plants,” the 
existence of which, as parasites in the skin, gives rise to 
certain cutaneous diseases. These two classes of germs are 
foreign to the present topic, which is Surgery; and I shall, 
therefore, confine my remarks to that group of vegetable 4 
ROBERTS, 
parasites to which the term bacteria has been given. These 
are the microorganisms whose actions and methods of growth 
particularly concern the surgeon. The individual plants are 
so minute that it takes in the neighborhood of ten or fifteen 
hundred of them grouped together to cover a spot as large as 
a full-stop or period used in punctuating an ordinary news- 
paper This rough estimate applies to the globular and the 
egg-shaped bacteria, to which is given the name “ coccus ” 
(plural, cocci). The cane- or rod-shaped bacteria are rather 
larger plants. Fifteen hundred of these placed end to end 
would reach across the head of a pin. Because of the resem- 
blance of these latter to a walking-stick they have been termed 
bacillus (plural, bacilli). 
The bacteria most interesting to the surgeon belong to the 
cocci and the bacilli. There are other forms which bacteriolo- 
gists have dubbed with similar descriptive names, but they are 
more interesting to the physician than to the surgeon. Many 
microbrganisms, whether cocci, bacilli, or of other shapes, are 
harmless ; hence they are called non-pathogenie, to distinguish 
them from the disease-producing or pathogenic germs. 
As many trees have the same shape and a similar method 
of growing, but bear different fruits—in the one case edible, 
and in the other poisonous—so, too, bacteria may look alike to 
the microscopist’s eye, and grow much in the same way, but 
one will cause no disease, while the other will produce.perhaps 
tuberculosis of the lungs or brain. 
Many scores of bacteria have been, by patient study, differ- 
entiated from their fellows and given distinctive names. Their 
nomenclature corresponds in classification and arrangement 
with the nomenclature adopted in different departments of 
botany. Thus, we have the pus-causing chain-coccus (strepto- 
coccus pyogenes), so-called because it is globular in shape; 
because it grows with the individual plants attached to each 
other, or arranged in a row like a chain of beads on a string; 
and because it produces pus. In a similar way we have the 
pus-causing grape-coccus of a golden color (staphylococcus 
pyogenes aureus). It grows with the individual plants arranged 
somewhat after the manner of a bunch of grapes, and when 
millions of them are collected together the mass has a golden- 
yellow hue. Again, we have the bacillus tuberculosis; the ADDRESS IN SURGERY. 
5 
rod-shaped plant which is known to cause tuberculosis of the 
lungs, joints, brain, etc. 
It is hardly astonishing that these fruitful sources of disease 
have so long remained undetected, when their microscopic 
size is borne in mind. That some of them do cause disease is 
indisputable, since bacteriologists have, by their watchful and 
careful methods, separated almost a single plant from its sur- 
roundings and congeners, planted it free from all contamina- 
tion, and observed it produce an infinitesimal brood of its own 
kind. Animals and patients inoculated writh the plants thus 
cultivated have rapidly become subjects of the special disease 
w7hich the particular plant was supposed to produce. 
The difficulty of such investigation becomes apparent when 
it is remembered that under the microscope many of these 
forms of vegetable life are identical in appearance, and it is 
only by observing their growth when in a proper soil that they 
can be/listinguished from each other. In certain cases it is 
quite difficult to distinguish them by the physical appearances 
produced during their growth. Then it is only after an animal 
has been inoculated with them that the individual parasite can 
be accurately recognized and called by name. It is known 
then by the results which it is capable of producing. 
The various forms of bacteria are recognized, as I have said, 
by their method of growth and by their shape Another 
means of recognition is their individual peculiarity of taking 
certain dyes, so that special plants can be recognized, under the 
microscope, by the color which a dye gives to them ; and 
which they refuse to give up when treated with chemical sub- 
stances which remove the stain from, or bleach, all the other 
tissues which at first have been similarly stained. 
The similarity between bacteria and the ordinary plants 
with which florists are familar is, indeed, remarkable. Bac- 
teria grow in animal and other albuminous fluids; but it is 
just as essential for them to have a suitable soil as it is for the 
corn or wheat that the farmer plants in his held. By altering 
the character of the albuminous fluid in which the micro- 
organism finds its subsistence, these small plants can be given 
a vigorous growth, or may be actually starved to death. The 
farmer knows that it is impossible for him to grow the same 
crop year after year in the same field, and he is, therefore, ROBERTS, 
compelled to rotate his'crops. So it is with the microscopic 
plants which we are considering. After a time the culture- 
fluid or soil becomes so exhausted of its needed constituents, 
by the immense number of plants living in it, that it is unfit 
for their life and development. Then this particular form will 
no longer thrive; but some other form of bacterium may find 
in it the properties required for functional activity, and may 
grow vigorously. It is probable that exhaustion or absence of 
proper soil is an important agent in protecting man from sick- 
ness due to infection from bacteria. The ever-present bacteria 
often gain access to man’s blood through external wounds, or 
through the lungs and digestive tracts ; but unless a soil suited 
for their development is found in its fluids, the plants will not 
grow. If they do not grow and increase in numbers, they can 
do little harm. 
Again, there are certain bacteria which are so antagonistic 
to each other that it is impossible to make them grow in com- 
pany, or to coexist in the blood of the same individual. For 
example, an animal inoculated with erysipelas germs cannot 
be successfully inoculated immediately afterward with the 
germs of malignant pustule. This antagonism is illustrated 
by the impossibility of having a good crop of grain in a field 
overrun with daisies. On the other hand, however, there are 
some microorganisms which flourish luxuriantly when planted 
together in the same fluid; somewhat after the manner ot 
pumpkins and Indian corn growing between the same fence 
rails. Others seem unwilling to grow alone, and only flourish 
when planted along with other germs. It is very evident, 
therefore, that bacteriology is a branch of botany, and that 
Nature shows the same tendencies in these minute plants as it 
does in the larger vegetable world visible to our unaided eyes. 
As the horticulturist is able to alter the character of his 
plants by changing the circumstances under which they live, 
so can the bacteriologist change the vital properties and activi- 
ties of bacteria by chemical and other manipulations of the 
culture substances in which these organisms grow. The power 
of bacteria to cause pathological changes may thus be weak- 
ened and attenuated; in other words, their functional power 
for evil is taken from them by alterations in the soil. The 
pathogenic, or disease-producing, power may be increased by ADDRESS IN SURGERY. 
7 
similar, though not identical, alterations. The rapidity of 
their multiplication may be accelerated, or they may be com- 
pelled to lie dormant and inactive for a time; and, on the 
other hand, by exhausting the constituents of the soil upon 
which they depend for life, they may be killed. 
It is a most curious fact, also, that it is possible by selecting 
and cultivating only the lighter colored specimens of a certain 
purple bacterium for the bacteriologist to obtain Anally a plant 
which is nearly white, but which has the essential character- 
istics of the original purple fungus. In this we see the same 
power which the florist has to alter the color of the petals of 
his flowers by various methods of selective breeding. 
The destruction of bacteria by means of heat and antiseptics 
is the essence of modern surgery. It is, then, by preventing 
access of these parasitic plants to the human organism (aseptic 
surgery), or the destruction of them by chemical agents and 
heat (antiseptic surgery) that we are enabled to invade by 
operative attack regions of the body which a few years ago 
were sacred. 
When the disease-producing bacteria gain access to the tis- 
sues and blood of human and other animals by means of 
wounds, or through an inflamed pulmonary or alimentary 
mucous membrane, they produce pathological effects, pro- 
vided there is not sufficient resistance and health-power in the 
animal’s tissues to antagonize successfully the deleterious in- 
fluence of the invading parasitic fungus. It is the rapid mul- 
tiplication of the germs which furnishes a continuous irritation 
that enables them to have such a disastrous effect upon the 
tissues of the animal. If the tissues had only the original 
dose of microbes to deal with, the warfare between health and 
disease would be less uncertain in outcome. Victory would 
usually be on the side of the tissues and health. The imme- 
• diate cause of the pathogenic influence is probably the chem- 
ical excretions which are given out by these microscopic 
organisms. All plants and animals require a certain number 
of substances to be taken into their organisms for preservation 
of their vital activities. After these substances have been 
utilized there occurs a sort of excretion of other chemical 
products. It is probably the excretions of many millions of 
microorganisms, circulating in the blood, which give rise to 8 
ROBERTS, 
the disease characteristic of the fungus with which the animal 
has been infected. The condition called sapraemia, or septic 
intoxication, for example, is undoubtedly due to the entrance 
of the excretory products of putrefaction bacteria into the 
circulation. This can be proved by injecting into an animal 
a small portion of these products obtained from cultures of 
germs of putrefaction. Characteristic symptoms will at once 
be exhibited. 
Septicaemia is a similar conditon due to the presence of the 
putrefactive organisms themselves, and hence of their pro- 
ducts, or ptomaines, also in the blood. The rapidity of their 
multiplication in this albuminous soil and the great amount of 
excretion from these numerous fungi make the condition more 
serious than sapraemia. Clinically, the two conditions occur 
together. 
The rapidity with which symptoms may arise after inocula- 
tion of small wounds with a very few germs will be apparent, 
when it is stated that one parasitic plant of this kind may, by 
its rapidity of multiplication, give rise to fifteen or sixteen 
million individuals within twenty-four hours. The enormous 
increase which takes place within three or four days is almost 
incalculable. It has been estimated that a certain bacillus, 
only about one-thousandth of an inch in length, could, under 
favorable conditions, develop a brood of progeny in less than 
four days which would make a mass of fungi sufficient to fill 
all the oceans of the world, if they each had a depth of one 
mile. 
Bacteria are present everywhere. They exist in the water, 
earth, air, and within our respiratory and digestive tracts. 
Our skin is covered with millions of them, as is every article 
about us. They can circulate in the lymph and blood and 
reach every tissue and part of our organisms by passing through 
the walls of the capillaries. Fortunately, they require certain 
conditions of temperature, moisture, air, and organic food for 
existence and for the preservation of their vital activities. 
If the surroundings are too hot, too cold, or too dry, or if 
they are not supplied with a proper quantity and quality of 
food, the bacterium becomes inactive until the surrounding 
circumstances change; or it may die absolutely. The spores, 
which finally become full-fledged bacteria, are able to stand a ADDRESS IN SURGERY. 
9 
more unfavorable environment than the adult bacteria. Many 
spores and adults, however, perish. Each kind of bacterium 
requires its own special environment to permit it to grow and 
flourish. The frequency with which an unfavorable combina- 
tion of circumstances occurs limits greatly the disease-producing 
power of the pathogenic bacteria. 
Many bacteria, moreover, are harmless and do not produce 
disease, even when present in the blood and tissues. Beside 
this, the white blood-cells are perpetually waging war against 
the bacteria in our bodies. They take the bacteria into their 
interiors and render them harmless by eating them up, so to 
speak. They crowd together and form a wall of white blood- 
cells around the place where the bacteria enter the tissue, 
thus forming a barrier to cut off the blood-supply to the germs 
and, perhaps, to prevent them from entering the general blood- 
current. 
The war between the white blood-cells and the bacteria is a 
bitter one. Many bacteria are killed; but, on the other hand, 
the life of many blood-cells is sacrificed by the bacteria poison- 
ing them with ptomaines. The tissue cells, if healthy, offer 
great resistance to the attacks of the army of bacteria. Hence, 
if the white cells are vigorous and abundant at the site of the 
battle, defeat may come to the bacteria; and the patient suffer 
nothing from the attempt of these vegetable parasites to harm 
him. If, on the other hand, the tissues have a low resistive 
power, because of general debility of the patient, or of a local 
debility of the tissues themselves, and the white cells be weak 
and not abundant, the bacteria will gain the victory, get access 
to the general blood-current, and invade every portion of the 
organism. Thus, a general or a local disease will be caused ; 
varying with the species of bacteria with which the patient 
has been affected, and the degree of resistance on the part of 
the tissues. 
From what has been stated it must be evident that the bac- 
terial origin of disease depends upon the presence of a disease- 
producing fungus and a diminution of the normal healthy 
tissue-resistance to bacterial invasion. If there is no fungus 
present, the disease caused by such fungus cannot develop. If 
the fungus be present and the normal or healthy tissue-resist- 
ance be undiminished, it is probable that disease will not 10 
ROBERTS, 
occur. As soon, however, as overwork, injury of a mechanical 
kind, or any other cause diminishes the local or general re- 
sistance of the tissues and individual, the bacteria get the 
upper hand, and are liable to produce their malign effect. 
Many conditions favor the bacterial attack. The patient’s 
tissues may have an inherited peculiarity, which renders it 
easy for the bacteria to find a good soil for development; an 
old injury or inflammation may render the tissues less resis- 
tant than usual; the point at which inoculation has occurred 
may have certain anatomical peculiarities which make it a 
good place in which bacteria may multiply; the blood may 
have undergone certain chemical changes which render it 
better soil than usual for the rapid growth of these parasitic 
plants. 
The number of bacteria originally present makes a differ- 
ence also. It is readily understood that the tissues and white 
blood-cells would find it more difficult to repel the invasion of 
an army of a million microbes than the attack of a squad of 
ten similar fungi. I have said that the experimenter can 
weaken and augment the virulence of bacteria by manipulat- 
ing their surroundings in the laboratory. It is probable that 
such a change occurs in nature. If so, some bacteria are more 
virulent than others of the same species ; some less virulent. 
A few of the less virulent disposition would be more readily 
killed by the white cells and tissues than would a larger 
number of the more virulent ones. At other times the danger 
from mierobic infection is greater because there are two species 
introduced at the same time; and these two multiply more 
vigorously when together than when separated. They are, in 
fact, two allied hosts trying to destroy the blood-cells and 
tissues. This occurs when the bacteria of putrefaction and 
the bacteria of suppuration are introduced into the tissues at 
the same time. The former cause sapraemia and septicaemia, 
the latter cause suppuration. The bacteria of tuberculosis are 
said to act more viciously if accompanied by the bacteria of 
putrefaction. Osteomyelitis is of greater severity, it is be- 
lieved, if due to a mixed infection with both the white and 
golden grape-coccus of suppuration. 
I have previously mentioned that the bacteria of malignant 
pustule are powerless to do harm when the germs of erysipelas ADDRESS IN SURGERY. 
11 
are present in the tissues and blood. This is an example of 
the way in which one species of bacteria may actually aid the 
white cells, or leucocytes, and the tissues in repelling an inva- 
sion of disease-producing microbes. 
Having occupied a portion of the time allotted to me in 
giving a crude and hurried account of the characteristics of 
bacteria, let me conclude my address by discussing the rela- 
tion of bacteria to the diseases most frequently met with by 
the surgeon. 
Mechanical irritations produce a very temporary and slight 
inflammation, which rapidly subsides because of the tendency 
of Nature to restore the parts to health. Severe injuries, 
therefore, will soon become healed and cured if no germs enter 
the wound. 
Suppuration of operative and accidental wounds was, until 
recently, supposed to be essential. We now know, however, 
that wounds will not suppurate if kept perfectly free from one 
of the dozen forms of bacteria that are known to give rise to 
the formation of pus. 
The doctrine of present surgical pathology is that suppura- 
tion will not take place if pus-forming bacteria are kept out of 
the wound, which will heal by first intention without inflam- 
mation and without inflammatory fever. 
In making this statement I am not unaware that there is a 
certain amount of fever following various severe wounds 
within twenty-four hours, even when no suppuration occurs. 
This wound-fever, however, is transitory; not high; and 
entirely different from the prolonged condition of high tem- 
perature formerly observed nearly always after operations and 
injuries. The occurrence of this “inflammatory,” “traumatic,” 
“surgical,” or “symptomatic” fever, as it was formerly called, 
means that the patient has been subjected to the poisonous 
influence of putrefactive germs, the germs of suppuration, or 
both. 
We now know why it is that certain cases of suppuration 
are not circumscribed but diffuse, so that the pus dissects up 
the fascias and muscles and destroys with great rapidity the 
cellular tissue. This form of suppuration is due to a particular 
form of bacterium called the pus-causing “ chain-coccus.” 12 
ROBERTS, 
Circumscribed abscesses, however, are due to one or more of 
the other pus causing microorganisms. 
How much more intelligent is this explanation than the old 
one that diffuse abscesses depended upon some curious char- 
acteristic of the patient. It is a satisfaction to know that the 
two forms of abscess differ because they are the result of in- 
oculation with different germs. It is practically a fact that 
wherever there is found a diffuse abscess there will be discov- 
ered the streptococcus pyogenes, which is the name of the 
chain-coccus above mentioned. 
So, also, is it easy now to understand the formation of what 
the old surgeons called “ cold ” abscesses, and to account for 
the difference in appearance of its puriform secretion from 
the pus of acute abscesses. Careful search in the fluid coming 
from such “ cold” abscesses reveals the presence of the bacillus 
of tuberculosis, and proves that a “ cold ” abscess is not a true 
abscess, but a lesion of local tuberculosis. 
Easy is it now to understand the similarity between the 
“ cold abscess ” of the cervical region and the “ cold abscess” 
of the lung in a phthisical patient. Bpth of them are, in fact, 
simply the result of invasion of the tissues with the ubiqui- 
tous tubercle bacillus; and are not due to pus-forming 
bacteria. 
Formerly it was common to speak of the scrofulous diathesis, 
and attempts were made to describe the characteristic appear- 
ance of the skin and hair pertaining to persons supposed to be 
of scrofulous tendencies. The attempt was unsuccessful and 
unsatisfactory. The reason is now clear because it is known 
that the brunette or the blonde, the old or the young, may be- 
come infected with the tubercle bacillus. Since the condition 
depends upon whether one or the other become infected with 
the generally present bacillus of tubercle, it is evident that 
there can be no distinctive diathesis. It is more than prob- 
able, moreover, that the cutaneous disease, so long described 
as lupus vulgaris, is simply a tubercular ulcer of the skin, and 
not a special disease of unknown causation. 
The metastatic abscesses of pyaemia are clearly explained 
when the surgeon remembers that the}' are simply due to a 
softened blood-clot containing pus-causing germs being carried ADDRESS IS SURGERY. 
13 
through the circulation and lodged in some of the small 
capillaries. 
A patient suffering with numerous boils upon his skin has 
often been a puzzle to his physician, who has in vain attempted 
to find some cause for the trouble in the general health alone. 
Had he known that every boil owed its origin to pus-bacteria, 
which had infected a sweat-gland or hair-follicle, the treatment 
would probably have been more efficacious. The suppuration 
is due to pus germs either lodged upon the surface of the skin 
from the exterior, or deposited from the current of blood in 
which they have been carried to the spot. 
I have not taken time to go into a discussion of the methods 
by which the relationship of microorganisms to surgical affec- 
tions has been established; but the absolute necessity for every 
surgeon to be fully alive to the inestimable value of aseptic 
and antiseptic surgery has led me to make the foregoing state- 
ments as a sort of resume of the relation of the germ theory 
of disease to surgical practice. It is clearly the duty of every 
man who attempts to practise surgery to prevent, by every 
means in his power, the access of germs, whether of suppura- 
tion, putrefaction, erysipelas, tubercle, tetanus, or any other 
disease to the wounds of a patient. This, as we all know, can 
be done by absolute bacteriological cleanliness. It is best, 
however, not to rely solely upon absolute cleanliness, which is 
almost unattainable, but to secure further protection by the 
use of heat and antiseptic solutions. I am fully of the 
opinion that chemical antiseptics would be needless if abso- 
lute freedom from germs was easily obtained. When I know 
that even such an enthusiast as I myself is continually liable 
to forget or neglect some step in this direction, I feel that 
the additional security of chemical antisepsis is of great value. 
It is difficult to convince the majority of physicians, and even 
ourselves, that to touch a finger to a door knob, to an assis- 
tant's clothing, or to one’s own body may vitiate the entire 
operation by introducing one or two microbic germs into the 
wound. 
An illustration of how carefully the various steps of an 
operation should be guarded is afforded by the appended rules, 
which I have adopted at the Woman’s Hospital of Philadel- 
phia for the guidance of the assistants and nurses. If such 14 
ROBERTS, 
rules were taught every medical student and every physician 
entering practice as earnestly as the paragraphs of the catechism 
are taught the Sunday-school pupil (and they certainly ought 
to be so taught) the occurrence of suppuration, hectic fever, 
septicaemia, pyeemia, and surgical erysipelas would be practi- 
cally unknown. Death, then, would seldom occur after surgical 
operations, except from hemorrhage, shock, or exhaustion. 
I have taken the liberty of bringing here a number of cul- 
ture tubes containing beautiful specimens of some of the more 
common and interesting bacteria. The slimy masses seen on 
the surfaces of jelty contained in the tubes are many millions 
of individual plants, which have aggregated themselves in 
various forms as they have been developed as the progeny of 
the few parent cells planted in the jelly as a nutrient medium 
or soil. 
With this feeble plea, Mr. President and Members of the 
Society, I hope to create a realization of the necessity for 
knowledge and interest in the direction of bacteriology; for 
this is the foundation of modern surgery. There is, unfortu- 
nately, a good deal of abominable work done under the names 
of antiseptic and aseptic surgery, because the simplest facts of 
bacteriology are not known to the operator. 
Rules to be observed in Operations at Dr. Roberts’s Clinic at the 
Woman’s Hospital of Philadelphia.—After wounds or operations 
high temperature usually, and suppuration always, is due to 
blood poisoning, which is caused by infection with vegetable 
parasites called bacteria. 
These parasites ordinarily gain access to the wound from 
the skin of the patient, the finger-nails or hands of the opera- 
tor or his assistants, the ligatures, sutures, or dressings. 
Suppuration and high temperature should not occur after 
operation wounds if no suppuration has existed previously. 
Bacteria exist almost everywhere as invisible particles in the 
dust; hence, everything that touches or comes into even 
momentary contact with the wound must be germ-free—tech- 
nically called “sterile.” 
A sterilized condition of the operator, the assistant, the 
wound, instruments, etc., is obtained by removing all bacteria 
by means of absolute surgical cleanliness (asepsis), and by the ADDRESS IN SURGERY. 
15 
use of those chemical agents which destroy the bacteria not 
removed by cleanliness itself (antisepsis). 
Surgical cleanliness differs from the housewife’s idea of 
cleanliness in that its details seem frivolous, because it aims at 
the removal of microscopic particles. Stains, such as house- 
wives abhor, if germ-free, are not objected to in surgery. 
The hands and arms, and especially the finger-nails of the 
surgeon, assistants, and nurses should be well scrubbed with 
hot water and soap, by means of a nail-brush, immediately 
before the operation. The patient’s body about the site of 
the proposed operation should be similarly scrubbed with a 
brush and cleanly shaved. Subsequently the hands of the 
operator, assistants and nurses, and the field of operation 
should be immersed in, or thoroughly washed with, corrosive 
sublimate solution (1:1000 or 1: 2000). Finger-rings, brace- 
lets, bangles, and cuffs worn by the surgeon, assistants, or 
nurses must be removed before the cleansing is begun; and 
the clothing covered by a clean white apron, large enough to 
extend from neck to ankles and provided with sleeves. 
The instruments should be similarly scrubbed with hot 
water and soap, and all particles of blood and pus from any 
previous operation removed from the joints. After this they 
should be immersed for at least fifteen minutes in a solution 
of beta-naphthol (1: 2500), which must be sufficiently deep to 
cover every portion of the instruments. After cleansing the 
instruments with soap and water, baking in a temperature 
a little above the boiling-point of water is the best sterilizer. 
During the operation the sterilized instruments should be kept 
in a beta-naphthol solution and returned to it when the operator 
is not using them. 
[The antiseptic solutions mentioned here are too irritating 
for use in operations within the abdomen and pelvis. Water 
made sterile by boiling is usually the best agent for irrigating 
these cavities, and for use on instruments and sponges. The 
instruments and sponges must be previously well sterilized.] 
Sponges should be kept in a beta-naphthol or a corrosive 
sublimate solution during the operation. After the blood 
from the wound has been sponged away, they should be put 
in another basin containing the antiseptic solution, and cleansed 
anew before being used again. The antiseptic sutures and 16 
ADDRESS IN SURGERY. 
ligatures should be similarly soaked in beta-naphthol solution 
during the progress of the operation. 
No one should touch the would but the operator and his 
first assistant. No one should touch the sponges but the 
operator, his first assistant, and the nurse having charge of 
them. No one should touch the already-prepared ligatures or 
instruments except the surgeon and his first or second assis- 
tants. 
None but those assigned to the \tTork are expected to 
handle instruments, sponges, dressings, etc., during the opera- 
tion. 
When anyone taking part in the operation touches an 
object not sterilized, such as a table, a tray, or the ether 
towel he should not be allowed to touch the instruments, the 
dressings, or the ligatures until his hands have been again 
sterilized. It is important that the hands of the surgeon, his 
assistants and nurses should not touch any part of his own 
body, nor of the patient’s body, except at the sterilized seat of 
operation, because infection may be carried to the wound. 
Rubbing the head or beard, or wiping the nose requires imme- 
diate disinfection of the hands to be practised. 
The trailing ends of ligatures and sutures should never be 
allowed to touch the surgeon’s clothing or to drag upon the 
operating-table, because such contact may occasionally, though 
not always, pick up bacteria which may cause suppuration in 
the wound. 
Instruments which fall upon the floor should not be again 
used until thoroughly disinfected. 
The clothing of the patient, in the vicinity of the part to be 
operated upon, and the blanket and sheets used there to keep 
him warm, should be covered with dry sublimate towels. All 
dressings should be kept safe from infection by being stored 
in glass jars, or wrapped in dry sublimate towels.