The Preparation of Surgical 
Dressings by Sterilization 
with Heat. Antiseptics 
as used in the Woman’s 
Hospital, Brooklyn, 
N. Y. 
CHARLES N. DIXON JONES, M. D., 
SURGEON TO THK HOSPITAL ; FELLOW OF THE BRITISH 
GYNECOLOGICAL SOCIETY, ETC. 
BY 
REPRINTED FROM 
Neto Yorft .pu&ical Journal 
for February 11, 1888. Reprinted from the New Yoric Medical Journal 
for February 11, 1888. 
THE PREPARATION OF SURGICAL DRESSINGS 
BY STERILIZATION WITH HEAT. 
ANTISEPTICS AS USED IN THE WOMAN’S HOSPITAL, 
BROOKLYN, N. Y* 
SURGEON TO THE HOSPITAL ; FELLOW OF THE BRITISH GYNAECOLOGICAL 
CHARLES N. DIXON JONES, M. D., 
SOCIETY, ETC. 
Gentlemen : It is no longer an hypothesis, hut a defi- 
nitely settled scientific fact, that suppuration can not be 
caused by chemical irritants; and it can be clearly demon- 
strated that wherever there is the formation of pus, micro- 
organisms have been at work. To paraphrase the law of 
Virchow, without the action of living bacteria there can be 
no suppuration. 
We may go further and state that certain micro-organ- 
isms have been proved to be the cause if not the actual 
materies morbi of the greater portion of diseases which 
affect the human race. To the medical man the study of 
the micro-organisms concerned in these processes becomes 
a subject of paramount interest and importance. 
As practical sanitarians and surgeons, it is desirable to 
know that the favorable conditions for the growth and de- 
* Read before the Section in Surgery of the New York Academy of 
Medicine, January 9, 1888. 2 
THE PREPARATION OF SURGICAL DRESSINGS 
velopment of disease-producing bacteria are dead organic 
matter, a limited supply of oxygen, water, and salts. And 
lienee it follows that scrupulous cleanliness, effectual drain- 
age, perfect ventilation, with copious supplies of sunlight, 
are of the utmost importance for all places of habitation, 
and especially hospital wards and sick-rooms. 
There would soon be an end to all animal life hut for 
the domination of physiological energies and the greater 
resistance offered by living tissue to the inroads of these 
parasites, which present a striking “ resemblance to beasts 
of prey in that they first kill and then devour.” 
It is thus seen that every cause which tends to weaken 
the physiological force of the human organism, which re- 
duces the vitality, prepares the way for a “ fatal assault by 
swarming multitudes of pathogenic bacteria.” Numerous 
experiments, extending over a period of several years, have 
been made by different observers, in order to determine the 
aetiology of the pus-forming process in man. Before bac- 
teriological science had reached that perfection of method 
which it has now attained, such experiments as those of 
Councilman and others seemed to show that the simple in- 
troduction of irritating substances into the animal tissues 
was sufficient to set up a process of inflammation followed 
by suppuration and general infection. Klemperer and 
Scheuerlin, thinking that the results obtained by other ob- 
servers might be due to imperfect sterilization of the skin 
of the animal experimented upon, performed a series of ex- 
periments, employing a more perfected technique, and both 
came to the conclusion that no suppuration would occur 
without the presence of micro-organisms. These observa- 
tions have been confirmed by Straus, Becker, Chauveau, 
Krause, and Ruys. 
Dr. Herman Knapp, in an admirable paper read before 
the Academy of Medicine in December of last year, shows BY STERILIZATION WITH HEAT. 
3 
that fermentation and putrefaction are always dependent 
upon the action of living bacteria. But the question of the 
parallelism of suppuration with the other two processes is the 
principal topic of the author’s studies, which he experiment- 
ally investigates under three heads: 1. Does traumatism of 
any kind produce suppuration ? In answer to this question 
he says: “ In extraction of cataract (in rabbits, of course) 
I have purposely bruised and lacerated the iris, evacuated 
almost all the vitreous, then stirred up the rest with a plati- 
num needle that had been previously brought to a glow, 
and finally scratched with the same needle the ciliary pro- 
cesses in every direction, yet no suppuration ensued, where- 
as the smoothest and most cautious operations were invari- 
ably followed by suppuration when the wound was con- 
taminated in some way by pyogenic fungi.” From this 
and other experiments he concludes that mere traumatism 
never causes suppuration. 2. Do foreign bodies as such 
cause the formation of pus? Foreign bodies introduced 
antiseptically into the anterior chamber of the eye never 
caused inflammation and suppuration. In answer to the 
third question, Are there any kinds of chemical agents that 
cause suppuration ? he reviews the experiments of other in- 
vestigators, and then relates a series of experiments of his 
own where chemical irritants were introduced with great 
precautions into the anterior chamber and under the skin, 
completely confirming the results of other investigators and 
concluding that suppuration in every case depends upon 
the action of living microbes. In this way the parallelism 
of the three processes—fermentation, putrefaction, and sup- 
puration—is established. 
Dr. Harold C. Ernst, in a most interesting and convinc- 
ing paper, relates the results of a series of some forty in- 
oculation experiments extending over a period of a year or 
more. In these experiments pure cultivations of seven 4 
THE PREPARATION OF SURGICAL DRESSINGS 
different forms of bacteria were used. Inoculations of 
pure gelatin cultivations of the Staphylococcus pyogenes 
aureus injected into a healthy guinea-pig produced death 
in twelve hours, and so in every case the experiments in- 
dicated that the virulence of these pathogenetic organisms 
was just as great at the end of a year, and after passing 
through a large number of generations, as when taken from 
their birthplace ; and he concludes that no form of sup- 
puration in man i§ unattended by bacteria. And lastly there 
are the experiments of Prudden on the aetiology of ulcera- 
tive endocarditis; the injection of Staphylococcus pyogenes 
aureus into the blood, combined with chemical or mechan- 
ical irritation of the valve or the endocardium, almost in- 
variably produced ulcerative endocarditis. 
Brassowski has corroborated the investigations of pre- 
vious observers in a series of observations made at Mikulicz’s 
clinic, and found that the Staphylococcus aureus and albus 
and Streptococcus pyogenes are the principal organisms 
found. It is usually supposed that in wounds healing by 
primary union and free from suppuration none of these 
organisms would occur. This observer has examined the 
secretions of wounds classed as strictly aseptic where pri- 
mary union occurred, and arrived at the following conclu- 
sions : Under antiseptic iodoform dressings only a part (one 
fifth) of the wound remains quite free from micro-organisms. 
Result, primary union. In a portion (one half) the Staphy- 
lococcus albus may be present (in small numbers), and two 
thirds of these heal by primary union ; in the other one 
third a slight suppuration occurs. In nine cases the Staphy- 
lococcus aureus and in two the Streptococcus pyoyenes oc- 
curred. Both cause certain suppuration, but by suitable 
drainage from the start this may be limited to the vicinity 
of the drain openings.* 
* “Wien. med. Woch.,” “An. of Surg.” BY STERILIZATION WITH HEAT. 
5 
The recent investigations of Dr. John E. Weeks, pub- 
lished too late for incorporation in this article, confirm the 
foregoing statements. 
Nelaton, who was counted among the most successful 
operators, was in the habit of saying that the man who 
discovered a method of preventing purulent infection would 
deserve to have erected in his honor a statue of gold. 
“ Lister * first taught us to apply systematically and 
accurately a method which would insure for our wounds 
protection against the hordes of intriguing microbes, and, 
although his particular method has been simplified and 
superseded in other countries, the underlying principles 
remain the same, and subtend all the modifications of the 
improvers.” 
The term “ Listerism ” or “ antiseptics ” has undergone 
all manner of misrepresentation and abuse. In a recent 
article I find it thus erroneously described: 1 
“ Listerism, then, is founded on the hypothesis that ordinary 
atmospheric air contains germs or seeds of disease, which, fall- 
ing upon the field of operation, develop there, and in that de- 
velopment are answerable for the majority of the unsuccessful 
results of surgical practice. To prevent that development there 
was instituted the practice of charging the air surrounding the 
patient, and especially the field of operation, with a substance 
which was supposed to have the effect of destroying, or at least 
of neutralizing, the influence of those germs. As you are all 
aware, the substance finally selected was carbolic acid. This 
was employed in the form of a spray to play upon the wound, 
and of a solution for the hands, instruments, and sponges, in 
the proportion of 2-J- per. cent., or 1 in 40.” 
This no more constitutes antiseptics than the ability to 
successfully extract a corn constitutes a surgeon. 
It is the fashion of the day to rail at antiseptics and cry 
* Morris. 6 
THE PREPARATION OF SURGICAL DRESSINGS 
for cleanliness ; it should be remembered that this is merely 
playing upon terms. Ordinary cleanliness is not asepsis; it 
is merely an attempt to obey the great moral precept. This 
has been conclusively demonstrated by Kummel. Ordinary 
washing of a part does not give an aseptic surface. If a 
few scales of the surface epithelium are removed from a part 
of the skin thus prepared and placed in a cultivation medi- 
um, colonies of one or more species of bacteria will develop, 
and pyogenic forms are not infrequent. “ Scientific anti- 
sepsis is an exalted degree of cleanliness, but this exalted 
degree of cleanliness can only be reached through scientific 
antisepsis.” 
What chemical purity is to the chemist, and sterilization 
to the bacteriologist, so is surgical cleanliness or antisepsis 
to the surgeon. 
There is a wide field for research in the determination 
of the real effect of disinfectants and antiseptics. The sub- 
ject is so beset with fallacies, leading in some cases to total- 
ly erroneous conclusions, that it is not surprising that one 
meets on all sides with conflicting statements. 
According to the investigations of Koch, the salts of 
mercury, and especially the chlorides, prove most valuable 
when heat is not permissible, though their poisonous nature, 
and the fact that the chloride is sometimes changed into 
inert calomel, is a drawback to their indiscriminate use. 
Ilerroun thinks the value of bichloride of mercury much 
overrated, as he has cultivated ordinary septic bacteria in 
albuminous filtrates containing 1 in 2,000. It is precipitated 
by albumins if used of greater strength, and is readily con- 
verted by the sulphur of albuminous bodies into inert mer- 
curic sulphide. 
Koch* has also tested the value of hot air and steam in 
the destruction of bacteria and their spores. Rolls of flan- 
* Cruickshank. BY STERILIZATION WITH HEAT. 
7 
nel with anthrax spores and a thermometer wrapped up in- 
side were subjected to steam, and the results compared 
with the' effects obtained in hot air. 
Thus, in hot air, four hours’ exposure to a temperature 
of 130° C. brought the temperature inside the roll to 85° 
C., and the spores were not destroyed; on the other hand, 
exposure to steam under pressure at 120° C. for an hour 
and a half raised the internal temperature to 117° C., and 
killed the spores. By such experiments the superior pene- 
trative power of steam-heat was established. 
Parsons and Klein have shown that complete penetra- 
tion of an object by steam-heat for more than five minutes 
is sufficient to kill all bacteria: 
Dr. Sternberg has recently published an exceedingly 
interesting paper upon the heat death-point of bacteria. 
He concludes that a temperature of 100° C., maintained 
for a period of five minutes, destroys the spores of all the 
pathogenetic organisms tested (about forty varieties). Most 
organisms are destroyed at a temperature of 62° C. 
In this connection it is important to refer to the conclu- 
sions of Dr. Fenger in a recent report of a series of investi- 
gations : 
“ What influence the asepsis of the material has on the re- 
sults of the operations as to death or recover? is a question far 
beyond the scope of these investigations. It would require a 
large statistical material of well-observed cases, and more work 
than could be done by one observer. But it may be safe to 
conclude that it is desirable to work through an abdominal 
operation with perfect asepsis everywhere, if such a thing is 
possible. The above investigations have shown that such per- 
fect asepsis can be attained. Thus, if we are ignorant of the 
extent of danger from non-sterile material, we are hardly jus- 
tified in trusting to the innocence or innocuousness of such an 
uncertainty, while we can have the asepsis of the material an 
absolute guarantee against the dangers of infection.” 8 
THE PREPARATION OF SURGICAL DRESSINGS 
The methods of the bacteriologists have made it possible 
for us to determine with absolute certainty whether the ma- 
terials used in our operation are sterile or not. By means 
of cultivation media we may easily determine (1) the con- 
dition of the atmosphere in our operating-room, (2) the 
aseptic condition of the hands, (3) sponges, (4) silk catgut, 
(5) instruments, etc. 
I here present eight cultivation tubes, which were pre- 
pared as follows: Previous to two operations performed 
about a week ago, pieces of the sponges, silk, and catgut to 
be used were cut off and placed in sterilized tubes; these 
were carried to the laboratory of the New York Polyclinic, 
and were carefully placed by Dr. Syms in sterilized pepto- 
nized beef gelatin. As you perceive, bacteria have devel- 
oped in the tube containing a piece of sponge removed at 
the close of the operation, and in one of the tubes contain- 
ing a piece of silk; the others have remained sterile. Un- 
der the circumstances, the experiments have been too few 
to give positive conclusions, but they illustrate what may 
be accomplished by this method. The time at my disposal 
has been too limited to go into any extended investigation 
in this direction, but I hope to still further pursue this 
interesting and practical line of work. 
The use of heat as a sterilizing agent by the bacteriolo- 
gist in the preparation of his pure cultivation, and the uni- 
form result which attends his experiments, has attracted the 
attention of some of the leading surgeons of Europe, and 
suggested to their minds that this agent might be employed 
in the preparation of their antiseptic dressings. 
Dr. Robert F. Weir, who has perhaps done more than 
any other surgeon in New York to popularize antiseptic 
methods, in a recent lecture referred to this agent as a ger- 
micide possessing advantages above the others in “ safety, 
cheapness,.and accessibility.” You are all familiar with the BY STERILIZATION WITH HEAT. 
9 
disadvantages and defects of the dressings prepared with 
carbolic acid and sublimate. I therefore desire to describe, 
in the brief space of time allotted to me, the apparatus, and 
a method of preparing a form of dressing which is intended, 
to overcome, to a certain extent, some of the difficulties 
with which we ordinarily contend. Neuber was the first 
to attempt a systematic method of aseptic wound treatment. 
Believing that all wound-diseases are due to the action of 
germs, he seeks to avoid their influence by an improved 
hospital hygiene, rather than by disinfection with a strong 
chemical solution. The operation-rooms are especially con- 
structed with a view to cleanliness and drainage. The air 
admitted to the operation-room is sterilized by first passing 
it through a furnace and then a cotton filter. 
The instruments, sponges, and dressings are sterilized 
by heat. The hands and region of operation are cleansed 
and sterilized with a l-to-1,000 sublimate solution. Only 
sterilized water is used for irrigation. By these means he 
hopes to gain an aseptic healing of large operation wounds 
without drainage. It can hardly he doubted that a wound 
kept sterile without the lavish expenditure of 5 per-cent, 
carbolic or sublimate solutions will heal more 
kindly than when these chemicals are used, but, as Nuss- 
haum well says, the aseptic treatment of a wound is an ideal 
realized with great difficulty, the sterilization of a wound 
still more difficult, and a break in a single link of the chain 
will destroy the whole. On a recent visit to the Burger 
Hospital, Strassburg, I was told by Professor Luecke that 
all the dressings used were simply sterilized and not im- 
pregnated with any chemical whatever, and he showed me 
an elaborate apparatus for their preparation. Here the most 
rigid aseptic wound-treatment is conscientiously followed 
—a circumstance which most certainly has no small share 10 
THE PREPARATION OF SURGICAL DRESSINGS 
in the production of the wonderful surgical results reported 
from this clinic. 
The wonderful results of thorough and intelligent anti- 
septic precautions are perhaps nowhere better shown than in 
Professor von Bergmann’s clinic, in Berlin. All those en- 
gaged in the operation are dressed in clean white gowns, and 
the most careful washing and disinfection of hands is observed 
before every operation. All the gauze employed for dress- 
ings is sterilized by means of steam-heat at a temperature 
of 212° F. This is prepared as follows: After freeing from 
grease it is placed in a steam sterilizer and exposed to the 
influence of flowing steam at the temperature of 100° C. 
for a period of fifteen to thirty minutes; by this means it 
becomes perfectly sterilized. This sterilized gauze, without 
further treatment, is used for dressings in all but the larger 
operation wounds, and small tufts are used instead of 
sponges. In the more serious operation, where profuse se- 
cretion is apt to occur from the wound, it is thought best to 
obtain whatever advantage may be derived from the im- 
pregnation of the gauze with corrosive sublimate, as all the 
operations are performed in the presence of from two hun- 
dred to three hundred students who come directly from the 
anatomical rooms. During the operation the wound is irri- 
gated with a l-to-2,000 bichloride solution, except in opera- 
tions on the abdomen, the pleural cavity, the mouth, rectum, 
and bladder, where l-to-1,000 salicylic acid or l-to-200 boric 
acid is employed. 
This convenient little apparatus, here shown, which we 
owe to American ingenuity, known as the Arnold automatic 
steam cooker, will be found indispensable to the surgeon. 
The sterilization is done by steam under slight pressure, 
which is generated very rapidly in the small, thin vessel 
under the pan. The pan is simply a reservoir to keep the 
steam generator supplied with water as it boils away. The BY STERILIZATION WITH HEAT. 
11 
steam passes up the tube into the drum. In this the per- 
forated receivers or wire baskets are placed and completely 
surrounded with live steam; in this way gauze, sponges, in- 
Fig. 1. 
strum ents, and silk are sterilized at a temperature of 212° 
F. without exposure to air or water. The steam, instead of 
escaping into the room, is caught by a receiver and con- 
densed, and flows back into the supply reservoir. 
With an ordinary Bunsen burner the water boils in less 
than five minutes, so that in a period of twenty minutes all 
the materials for an ordinary operation may be prepared. 
In private practice the sterilizer may be placed on the 
cooking range, or a kerosene-oil stove can be used. I ordi- 
narily place the apparatus on a stove near the operating-ta- 12 
THE PREPARATION OE SURGICAL DRESSINGS 
ble, so that during the etherization of the patient my ma- 
terials are being prepared. When the patient is fully anaes- 
thetized, the instruments and silk are removed from the 
sterilizer, and the dressings left within until needed. 
I also exhibit a more complicated apparatus which is a 
modification of Koch’s sterilizer (Fig. 2). It consists of a 
Fig. 2. 
Fig. 3. 
cylindrical vessel of strong tin plate, about half a metre or 
more in length, 25 ctm. in diameter, jacketed with thick 
asbestus to prevent loss of heat, and provided with a conical 
cap. The lid is also covered with asbestus, which is per- 
forated at the apex to receive a thermometer. Inside the 
vessel is an iron grating or diaphragm about two thirds the 
way down, which divides the interior into two chambers, the 
upper or steam chamber and the lower or water chamber. BY STERILIZATION WITH HEAT. 
13 
A gauge outside mai'ks the level of the water in the lower 
chamber; this should be kept about two thirds full. The 
apparatus stands on three legs and is heated from below 
with three Bunsen burners. When the thermometer indi- 
cates 100° C. the lid is removed and the dressings are low- 
ered in a basket by means of a hook and string and the lid 
quickly replaced. 
It requires twenty-seven minutes for the thermometer to 
indicate 100° C. with five pints of water in the receiver, and 
another fifteen minutes to completely sterilize the material 
placed within. 
I believe the ideal apparatus to be one constructed on 
this model but made of riveted copper so that the water 
can be drawn off and the material dried at a temperature of 
212° F., as indicated in the diagram (Fig. 3). 
On removal from the apparatus the dressings dry on ex- 
posure of two to three minutes to the air. Or they may be 
placed in a drying oven for a few minutes. 
Antiseptics in Abdominal Surgery.—Some few years 
ago Wegner made the remark that he and his contempo- 
raries had doubtless all been reared in the fear of the Lord 
and the peritona3um, but now the peritonaeum had ceased to 
be a surgical “ noli me tangere.” 
I would be the last to decry the marvelous progress 
which abdominal surgery has made under the influence of 
antisepticism, yet I believe that our antiseptic solution can 
not be used in abdominal surgery with that perfect freedom 
which has been so efficacious in preventing surgical infec- 
tion in other classes of operations. Here the enormous ab- 
sorptive power of the peritoneal cavity dominates the scene. 
In looking over the records of surgical operations, the deaths 
from mercurial poisoning are not a few. A recent writer 
says: “ To meet this evil I have gradually diluted my spray and 
solutions, so as to reduce the whole question to one of clean- 14 
THE PREPARATION OF SURGICAL DRESSINGS 
liness, and, I am happy to say, with the effect of very great- 
ly adding; to the success of my ovariotomy work.” While 
I can not indorse this practice, -yet it has been my en- 
deavor during the past year or so to get along as far as 
possible without the use of carbolic acid and sublimate dur- 
ing the progress of an abdominal operation, and with the 
result of making the convalescence of the patient more nor- 
mal in every respect. To make myself more clearly under- 
stood, perhaps I can not do better than give a descrip- 
tion of antiseptics as now practiced at the Woman’s Hos- 
pital, Brooklyn. All efforts arc directed with scrupulous 
care to the disinfection of the instruments and person. The 
sponges are prepared according to the method described by 
Dr. Weir, and are used hut once. Recognizing and fully ap- 
preciating the difficulty of securing at all times the intelligent 
co-operation of assistants and nurses, the number of assist- 
ants who touch anything in connection with the operation 
is limited to one. All instruments are scrubbed with a 
brush and soap before and after each operation. Previous 
to each operation they are placed in the sterilizer for fifteen 
minutes and then transferred to boiled water. All towels 
and silk used about the operation are sterilized by boiling. 
The vessels and basins used about the operation, consisting 
of glass or granite iron ware, are partially filled with water 
and placed in an oven for a period of two hours. The wa- 
ter used for sponges and irrigation is boiled and then cooled 
in covered vessels. The region of operation is washed, 
shaved, and then cleansed with a saturated solution of iodo- 
form in ether. The room used for the operation is thor- 
oughly cleansed and fumigated before each operation. 
This hospital is the first to have a separate building de- 
voted exclusively to abdominal surgery. This pavilion is 
separated from the main building, not by a space of a few 
hundred feet, but by a distance of two miles, so that there BY STERILIZATION WITH HEAT. 
15 
is no communication whatever. We now come to the prac- 
tical question, Do the results justify all these extraordinary 
precautions and untiring-vigilance on the part of the sur- 
geon ? In answer to this question I will read you a report 
of the operations performed in this hospital from January 1, 
188V, to December 31 of the same year: 
Thirty-five abdominal sections for the removal of ova- 
rian tumors and diseased uterine appendages; of these 35 
patients but one died, and this operation was not performed 
by the regular staff of the hospital. 
Twenty of these cases required the use of a drainage- 
tube. 
The abdominal cavity has been opened five times in the 
removal of .cancerous uteri through the vagina; all of these 
patients have recovered. 
There has been one case of suprapubic amputation of 
the uterus, with its annexa, for myoma, which ended in re- 
covery. 
There have been three exploratory incisions ; in one of 
them, a case of peritonitis, the patient succumbed from 
shock. 
There have been four operations for the radical cure of 
hernia, all of which, ended in recovery. 
Fifty-two operations for lacerations of the cervix uteri 
and perinteum ; all the patient,s recovered. 
Besides these cases there have been performed in the 
children’s department 14 cuneiform and 22 subcutaneous sec- 
tions of the bones of the limbs for the cure of deformities, 
none of which have been attended by serious symptoms. 
There have been a variety of other operations which I 
will not take your time to enumerate. The two deaths 
above recorded constitute the total mortality. 
With one exception, these operations have been per- 
formed either by Dr. Mary D, Jones or myself. STERILIZATION OF SURGICAL DRESSINGS. 
16 
I take this opportunity of presenting Collins’s new 
haemostatic clamp forceps, which is the simplest and most 
easily cleaned of any forceps with which I am acquainted, 
and I have adopted it almost exclusively in my practice. 
Messrs. Tiemann & Co. have adapted this lock to for- 
ceps and scissors of different sizes. The lock is simplicity 
itself; attached to one blade there is a round pivot, which 
fits into an opening in the other blade. In order to hold 
the two blades in close apposition, as the forceps is closed, 
the male blade passes beneath a projecting arm attached to 
the female blade, somewhat similar to a Simpson obstetrical 
forceps. Its advantages are: (1) there are no crevices to hold 
dirt, so that it can be readily cleaned ; (2) the lock can not 
be twisted off by clumsy nurses; (3) the blades are held 
firmly together, so that there is no wabbling. REASONS WHY 
Physicians Should 
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