SURGICAL CLEANLINESS, 
An Address delivered at the Fortieth Annual 
Meeting of the Dewitt County (Illinois) 
Medical Society, April 1^., 1896. 
BY 
GEORGE NOBLE KREIDER, A. B., M. D„ 
SPBINOFIELn, ILL. 
REPRINTED FROM THE 
Neto XorU jMeTncal journal 
for June 6, 1896. Reprinted, from the New York Medical Journal 
for June 6, 1896. 
SURGICAL CLEANLINESS, 
AN ADDRESS DELIVERED AT THE FORTIETH ANNUAL MEETING 
OF THE DEWITT COUNTY (ILLINOIS) MEDICAL SOCIETY, 
April 1896. 
By GEORGE NOBLE KREIDER, A. B., M. D., 
SPRINGFIELD} "ILL. 
At this anniversary celebration of a long existence for 
a western medical organization I take the liberty of men- 
tioning the trite fact that surgery has made vast progress 
since this society was founded. My object in stating this 
fact is not to unduly traduce our ancestors or glorify our- 
selves. Our grandfathers would be the first to acknowl- 
edge the progress were they permitted to meet with us to- 
day, and we should be mindful of their success amid diffi- 
culties which are now happily largely overcome. There is 
yet too much to be learned for us to boast of our present 
advancement, great though it undoubtedly is. 
We live in a progressive age and ours is a progressive 
profession. T make bold to say that no profession has so 
rapidly perfected itself in the last forty years as has the: 
medical profession. No other profession has done so much 
for or given so charitably to the world its advances and 
discoveries as has the medical profession. Within the last 
year Professor N. S. Davis, Jr., stated to me his firm be- 
Coptbight, 1896, by D. Appleton and Company. 2 
SURGICAL CLEANLINESS. 
lief that the medical profession was better educated than 
the legal and clerical professions were. Upon my remarking 
that physicians deserved great credit for their learning be- 
cause they had been compelled to work out their own sal- 
vation, he replied : " Yes; and it was because they had been 
compelled to rely on themselves for what they had done 
that they had reached this proud position." How true 
this is! The clergy are coddled and helped from the 
time they announce their intention of preaching the word. 
They seldom pay any tuition in the schools, and their bed, 
board, and clothing are furnished them at a discount. The 
lawyers secure from the State all legislation necessary to 
advance their interests and increase their emoluments. 
But the doctor, laboring humbly as a student and silently 
as a practitioner, has to fight his battle unaided from the 
time he takes up life's battle until he lays it down. The 
clergy accept too often his charity, and reward it by 
recommending some quack doctor or patented fraudulent 
medicine. The law demands tedious and valuable services 
from the doctor for which it pays nothing, or a miserable 
pittance. This harsh training is what makes the doctor 
bold and self-reliant. It enables him to forgive the follies 
and even crimes of the people, and strive honestly, in the 
vast majority of cases, to seek only after the truth. He 
advocates higher education of his student, not in the 
trades-union spirit which would limit the number of ap- 
prentices, but with the noble desire that his successor may 
be more skilled than he is himself. These are some of the 
reasons why we love our profession. I am proud that I 
have had the good fortune to spend as much of my life as 
I have in the ranks of a profession which has done and is 
doing so much for mankind, individually and collectively. 
It is not possible for me or for you, perhaps, to become a 
leader in medicine and surgery, but we may reflect some of SURGICAL CLEANLINESS. 
3 
the greatness of those who are leaders by being in their 
company. We can all, however, do good, and we owe it to 
ourselves and the community in which we live to so equip 
ourselves that we may older the best advice which science 
affords and thereby fulfill the chief end of our existence. 
" Qui 7ton proficit deficit "-he who does not move forward 
moves backward-is nowhere so true as in our profession. 
Keep abreast of the times or drop out of sight, is the law of 
our calling. 
I have been in practice for about sixteen years, the 
greater part of the time in general work, but always with 
an eye to a surgical specialty. Owing to circumstances 
which I need not here detail my ambition was not fulfilled 
until January 1, 1891, when I was appointed one of the 
surgeons of St. John's Hospital, of Springfield. This 
hospital contains about a hundred beds and occupies a 
substantial brick and stone building of modern construc- 
tion. Tt is under the management of the Sisterhood of St. 
Francis, an order of German origin, but having a consider- 
able growth in this country. The thoroughness and mili- 
tary order inherent in the German character is seen in the 
work of the sisters, and this, when properly trained, has 
been of great advantage in arranging the surgical work, 
which will be shortly detailed. It had then been cstab 
lished about fifteen years. The surgical department had 
not grown with the growth of the hospital itself or the 
city. Its equipment in operating room, instruments, ap- 
pliances, and training of nurses was extremely primitive. 
Antiseptic surgery was practised in a deceptive way- that 
is, it was imagined that there was antiseptic surgery, but 
really none was practised, and so the worst of all decep- 
tions, self-deception, existed. For sterilizing the hands, a 
little carbolic acid was poured into water and the hands 
passed through the solution in a perfunctory manner. No 4 
SURGICAL CLEALLINESS. 
thought was given to the nails, and no facilities existed for 
washing the hands properly. This is a sample of the condi- 
tion which existed when T entered upon my work. 1 have 
thought it might be of interest and benefit to recount on 
this occasion in brief the difficulties which were met and 
how they were overcome. I hope in this way to illustrate 
the development from the old to the newer way of practis- 
ing surgery. The surgeon of to-day must obey the injunc- 
tion of the Book of Common Prayer and approach his 
work with a pure heart and clean hands. Every one here 
knows that cleanliness is the foundation stone of modern 
surgery, but I venture to say that very few of my hearers 
could carry out surgical cleanliness unless they have made 
a special study of it and had cultivated for some time the 
" antiseptic conscience." One of the axioms of modern 
surgery is a legend which is inscribed on the walls of the 
operating room of a celebrated operator-viz,, " Nothing is 
clean which can be made cleaner." This should be the 
motto of each of us as regards the room in which we oper- 
ate, the hands, instruments, and the patient to be operated. 
But to return to the consideration of the hospital, 
where I can best illustrate my points. I found in the hos- 
pital five years ago three operating rooms, situated in 
different parts of the house, not one of them properly 
located or equipped, heated, or lighted. 
Two of them were at once abandoned, and a single 
room of ample size, facing the north, on the upper floor, 
was selected, where a top light could be secured. Ade- 
quate heat was introduced, and a full set of sterilizing ap- 
paratus for the hands, instruments, water, and dressings was 
provided. For cleansing the hands a large porcelain-lined 
sink was erected with an ample supply of hot and cold water 
from two faucets, so that two persons could use it at the 
same time. Some few years ago I was about to begin prepa- SURGICAL CLEANLINESS. 
5 
rations for operating on a severe case of appendicitis. I 
requested a colleague who was to assist me to give his hands 
a thorough washing. His reply was that it was not neces- 
sary. as he had washed his hands just before he left his home, 
a half hour before. Of course, the members of this intelli- 
gent society would not be guilty of this gross offense against 
modern surgical cleanliness, but I am sure that too many 
of our profession do not even now wash their hands after 
leaving home, and as a consequence of their uncleanliness 
great suffering results, and many mysterious dispensations of 
Providence occur which result in death. The care of the 
doctor's hands might well be made the title of a whole vol- 
ume, so great is its importance and so much has been the 
study devoted to the best way of caring for them. Suffice 
it here to say that elaborate experiments have been made 
to determine how long and with what kind of instrument 
and soap it is necessary to scrub the hands to make them 
surgically innocuous. My habit is to wash the hands with 
soft soap and this brush for five minutes. To be sure of 
the time, and for convenience, I have this sandglass hung 
upon the wall above the sink. 
This sandglass is used by the housewife for conven- 
ience in determining the length of time she should boil 
eggs, but we use it for the more noble and glorious pur- 
pose of asepsis. ' I discovered this valuable little assistant 
in one of our tin stores. We use one of these also for deter- 
mining the proper length of time for boiling the instru- 
ments for sterilizing them. After the hands are washed 
with soap and water the nails are trimmed with a pair of 
small scissors. Scissors I find much more valuable for this 
purpose than the knife blade or any instrument for scraping 
the nail. To avoid the irritation of the skin resulting from 
so thorough and frequent washing, I have a bottle of 
glycerin, rose water, and tincture of benzoin on the shelf 6 
SURGICAL CLEANLINESS. 
above the sink, and, by using it frequently, I manage to 
keep my hands soft and free from chaps. This brush is 
kept in a solution of bichloride when not in use, to prevent 
the growth of germs in its fibres and to prevent the trans- 
fer of disease from one person to another. I always use 
this particular form of brush (ladies' hand brush, second 
quality, made by E. Clinton & Co., of Philadelphia) be- 
cause the bristles are not too stiff and when soaked do not 
lacerate the skin. After one has suffered from mild de- 
grees of blood poisoning from slight abrasions about the 
hands, he will take any precaution to prevent these abra- 
sions. After thorough cleansing, as has just been stated, 
the hands are vigorously rubbed with alcohol for two 
minutes, and finally with bichloride solution for three min- 
utes more, and if this has been conscientiously carried out 
in every detail the hands can be said to be perfectly aseptic 
and capable of doing no harm. It will be observed that 
bichloride or carbolic acid plays a very small part in the 
preparation of the hands, and it can not be too often 
repeated that merely soaking the hands in a solution 
of either of these germicides is of no value at all. The 
grease and dirt of the hands must be removed by an alka 
line soap and the expenditure of good, strong rubbing. If 
anything is to be left undone it should be the use of the anti- 
septics. Especial attention is paid to the skin of the pa- 
tient whenever it is possible. A full bath is always given 
and a poultice of soft soap is put on the site of the operation 
for twenty-four hours before the operation is to take place. 
The site is then shaved, scrubbed, and washed with alcohol 
and bichloride, always remembering that soap and water 
are of more value than the other articles mentioned. 
I can not let this opportunity pass without adding a 
word concerning the practice of obstetrics, in which the 
importance of especial care of the hands and female geni- SURGICAL CLEANLINESS. 
7 
tals is not yet understood, as I firmly believe. The precau- 
tions I have mentioned are to be carried out by the attending 
physician every time he undertakes a case of obstetrics. 
I think the idea expressed some years ago that a physician 
should use the same precautions in attending a case of 
obstetrics that a surgeon would in undertaking a surgical 
operation is entirely correct. To me the ideal way of 
attending a case of obstetrics would be for the physician to 
see his patient some weeks before the expected confinement 
and, after examining the urine, to measure her pelvis. The 
measurements and urine having been found right, she 
should be warned about the cleanliness of her person and 
instructed how she can best make the necessary cleansing 
of her parts. 
Then, at the time of confinement, the physician should 
go with his suit of linen clothing newly washed, which 
should be drawn on over his usual clothing. He should 
have a clean nailbrush for his hands, scissors for trimming 
his nails, alcohol and bichloride tablets for sterilizing the 
hands, sterilized oil for anointing the fingers and instru- 
ments, a sterilized Kelly cushion for catching the discharges 
and keeping the bed clean. If these precautions, which I 
have only stated in brief, were carried out, there would be 
no milk fever, malarial fever, or plainly puerperal fever, 
such as is too often found even now. I think I appreciate 
the difficulties with which physicians have to contend, but 
still I believe that much might be done to better the con- 
ditions under which they work if they only tried to en- 
lighten the people on this important subject. 
I will mention just here another very important point 
in which I have only recently made a radical change from 
the former practice. I refer to the simple matter of giving 
a hypodermic injection. You are fortunate if you have 
never had an abscess follow a hypodermic injection. I 8 
SURGICAL CLEANLINESS. 
have had several times, but fortunately they were insignifi- 
cant. Recently in the hospital one of the nurses became 
careless, and as a result the life of a valued patient of my 
colleague was nearly sacrificed. The needle was inserted 
on the outer surface of the arm. A large abscess devel- 
oped, with high fever and septicaemia of a violent character. 
Fortunately, it was overcome and the patient saved. The 
lesson was sufficient to cause me to investigate the subject, 
and I soon found that this experience was not unique. 
Tuberculosis, malignant pustule, purulent oedema, erysip- 
elas, and perhaps other diseases have been transmitted by 
the hypodermic syringe, and not a few persons have lost 
their lives in this manner. 
In order that no more such dangerous accidents may 
occur I have directed that particular attention should be 
paid to the syringe, the skin, and the solution containing 
the medicine. I have introduced the use of this syringe. 
It can be thrown into water and boiled without injuring 
any of its parts. I now direct that the site of the injection 
should be cleansed with soap, water, and alcohol, and a 
piece of sterilized gauze. Thirdly, I have directed that the 
solutions of morphine or other drug to be injected be made 
up with a one-per-cent, solution of carbolic acid. By car- 
rying out these precautions we can be reasonably certain 
that no more abscesses will result from hypodermic injec- 
tions. The syringe should be washed out with sterilized 
water or else be boiled after each using. 
Another convenience which we use a great deal, and 
which you have all doubtless found very valuable, is the 
Kelly rubber cushion. A friend of mine, a prominent Chi- 
cago surgeon, condemns this cushion in the strongest 
terms, because, he says, it is only a collector of filth which 
can not be got rid of after the first using. I think I 
have overcome all objections to this valuable cushion by SURGICAL CLEANLINESS. 
9 
first having it well washed with soap and hot water and 
then keeping it immersed in a bichloride solution of 1 to 
2,000, which is contained in a five-gallon stone jar. In 
this jar we keep all our rubber tubing, which is first washed 
with sapolio before it is immersed. In place of the glass 
douche, jar, or rubber bag we use this very elegant two- 
quart metal cup covered inside with white and outside 
with blue enamel, and which, so far as I know, can only 
be obtained from the Holekamp-Moore Company, of St. 
Louis. 
The tips are made of glass of various forms, and are 
also to be obtained from the same St. Louis firm. 
The tables in use are as far as possible made with glass 
tops, so that nothing can be absorbed from them, and they 
are thus easily cleaned. Glass and easily cleansed materials, 
such as this blue and white ware, are used as much as pos- 
sible throughout the hospital. 
For cleansing the instruments, a one per-cent, solution 
of carbonate of sodium is used, in which they are boiled for 
five minutes. The soda serves a good purpose in dissolv- 
ing off the grease and other foreign matter which may 
have contaminated them, and also prevents them from rust- 
ing, which" is a very important point in itself. The heat 
of the boiling water for five minutes completes this work 
of disinfection and enables us to use the instruments in 
any given case, no matter how foul the wound may have 
been in which they were used an hour previously. For 
this purpose I use, in working away from the hospital, a 
portable sterilizer, which can be easily slipped into the 
hand satchel. If some boiler like this is not at hand, an 
ordinary granite iron roasting pan may be used and will be 
found very valuable. After taking the instruments from 
the boiler they are not laid in a carbolized solution, as was 
formerly done, but placed on a sterilized towel which ab- 10 
SURGICAL CLEANLINESS. 
sorbs the water and prevents carrying into the wound any 
of the solution, which might at times be irritating. 
Knives are sterilized as well as other instruments by 
boiling, but to prevent their dulling from the ebullition of 
the water it is necessary to place them securely in a holder. 
Sponges have been entirely abandoned for some years 
and their place taken by small pieces of gauze, which are 
kept in metal cases after undergoing the process of steam- 
ing under slight pressure for forty-five minutes. For ab- 
dominal work this gauze is cut into large squares and a 
piece of white tape sewed to one corner. When one of 
these pieces is placed in the abdominal cavity an artery 
forceps is clamped to this tape and the tape and forceps 
allowed to hang out of the way at the side of the abdomi- 
nal wall. During an operation one nurse has charge of 
this case, and her sole duty is to raise the lid and allow 
the operator or his assistant to take out a piece of the 
gauze as may be required, when the lid is quickly closed 
and contamination of the remaining contents prevented. 
In this way the gauze only passes through one person's 
hands in reaching the wound, and the possibility of con- 
tamination is reduced to a minimum. Cases similar to 
this are used for sterilizing and holding towels* operating 
gowns, and sheets. 
Finally, I will mention that our operating room is 
equipped with a special table which is easily cleansed, and 
which enables us to place our patient in almost any posi- 
tion for operating. 
For all purposes we use only sterilized water. It is 
sterilized by boiling it for ten minutes in a special kettle, 
provided with a jacket, lid, and faucet from which the 
water runs into bottles holding about two thousand cubic 
centimetres. We find Buffalo lithia water bottles very 
good and cheap for this purpose. Besides the simple SURGICAL CLEANLINESS. 
11 
sterilized water we keep bottles containing solutions of 
carbolic acid, bichloride, and salt. The tendency is to 
abandon all medicated solutions and to rely altogether on 
simple sterilized water or the normal salt solution. 
Tn this short description of my experience in changing 
from the methods of the old to the new surgery I hope I 
have been able to convey to the members of this society 
some of the principles which distinguish the one from the 
other. These simple means, thoroughly carried out, are 
the perfect cause of the present advanced status of sur- 
gery. And yet, simple as they are, I believe that they are 
not yet appreciated by the majority of the profession. If 
I have in any way been able in this paper to call your at- 
tention to the importance of surgical cleanliness in the 
practice of your profession in all its branches I will have 
accomplished some good. In conclusion, I will say that in 
no particular has the advance of medicine and surgery been 
so marked as in the changes which have occurred in the 
hospitals. Instead of being veritable pesthouses, which 
were only to be entered in the last extremity, and which 
might well have had placed over their doors the famous 
quotation, " Leave all hope behind, ye who enter here," we 
find them to-day, when properly located and conducted, 
veritable houses of health and hotels of God, as they are 
so beautifully designated in the French language. The New York Medical Journal. 
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