may have been childish episodes between boys and girls which would astonish and shock parents. How little we know of the inner life of growing girls and boys! Hence the importance of confidence between parents and children; of wise selection of reading, since silly, erotic stories stimulate unduly the developing sex-instinct. Servants very often pervert the minds and bodies of children, and girls who know that they are doing wrong are liable not to mention such things to their mothers. While it does not seem wise to teach sex-hygiene in the schools, except individually, enough can be taught through nature-study of plants, insects, and animals, by a tactful teacher. Not all parents nor all teachers are adapted to such teaching, but it naturally comes through these sources and the family physician. At puberty the girl is neither child nor woman; it is a trying time for her and she needs sympathetic, kind, and wise guidance. She is romantic, emotional, has many thoughts which she would not confess, is easily led into wrong habits. Many a case of masturbation begins at puberty, from the beginning of sex-consciousness, or the teachings of other girls. Cold sprays, out-ofdoor exercise, early rising, a hard bed, airy, cool sleeping-rooms, self-control in everything, clean-minded associates, avoidance of too great religious emotionalism, too engrossing friendships, or undue stimulus for dancing, are all important in the hygiene of puberty. The brooding, irritable, moody or hysterical, sulky, idle girl, whose mother has not her confidence is liable to masturbatea malady mysterious to the mother is quickly suspected by the physician consulted. Often the mere presence of the mother deters the physicians from confronting the girl with the habit, but in a few minutes alone an admission can usually be elicited by a tactful physician and often the statement that unless she can control it, the mother will have to be told, is a long step towards its cessation. Doubtless many excellent women would be indignant and shocked if told that their conversation is often unsuitable for a young Matters girl's ears. But such is the case. are discussed in the presence of young girls that should not be mentioned, as marital relations, details and symptoms of pregnancy, illegitimate pregnancy, confinement, and abortion. This is wholly unnecessary, as well as unwise, and often stimulates her curiosity and fancies about sexual matters to an unhealthy degree. The mind of a young girl is plastic, full of curiosity and surmise, and may receive impressions which will disgust or repel, or on the other hand tend to make her careless and coarse. It is a bad plan to be frequently joking a young girl about some "beau." She should have her childhood as long as possible, until in the traditional course of development her mind turns to such matters. Self Confidence It is wonderful what a power self confidence has to marshal all the faculties and unite their strength in one mighty cable. No matter how many talents a nurse may possess, if she be lacking in self confidence she can never use them to the best advantage; she cannot unify their action and harmonize their power so as to bring them In order to succeed in life, it is just as necessary to have self trust as to have ability, and if you do not possess the former, one of the best means of acquiring it is to assume that you already have it. Carry yourself with a self-confident air, and you will not only inspire others with a belief in your ability, but you will come to believe in it Surgical Technic in Orthopaedic Surgery* WALTER G. ELMER, M. D. Instructor in Orthopedic Surgery in the University of Pennsylvania. My purpose in presenting this paper is to call attention to several important ways in which the wound may become contaminated by organisms far more potent than the skin coccus, types of infection which may defeat the operation and even be a serious menace to the life of the patient. The responsibility rests largely upon the nursing staff and the technic of the operating room is good or bad according to the intelligence and ability of the nurses in charge of it. The head nurse must directly and personally supervise the work of her assistants, and the directress of nurses is responsible for the head nurse. The most important feature of a large general hospital is the operating room-and this includes, of course, its personnel. The visiting surgeon in performing a series of operations expects everything to proceed smoothly and without friction-doctors and nurses working in harmony-and all co-operating to secure the best results. When one operation follows another in quick succession-perhaps not five minutes in the interval between them—it is not always possible to relegate the septic cases to the last, as it sometimes happens that infectious material is encountered when it is not expected. A gall-bladder may be septic or an appendix may be lying in a small pocket of pus. A clean pelvic operation may reveal a pyosalpinx. Therefore, in every series of operations one must take it for granted that they may not all be clean cases. The operating-room nurse and her assist ants must have absolute confidence in their ability to so conduct the technic that there is no possibility of carrying infection from *Abstract of paper read before the Philadelphia Academy of Surgery. one patient to another. This requires constant vigilance and can only be entrusted to a highly trained head nurse. In most hospitals it is customary for the directress of nurses to make a daily tour of inspection of the hospitals under her charge. She visits the private patients and the ward patients, sees that the wards are clean, looks at the bed linen, walks into the kitchen and pantry, opens the doors of cupboards and closets, inspects the toilet-rooms, and in a hundred other ways assures herself that the hospital is being conducted in a clean and orderly manner. And yet more important than all these is the operating room, and I would suggest that the directress of nurses occasionally vary her routine and go unannounced into the operating room or the clinical amphitheatre when a series of operations is in progress and remain throughout an entire forenoon or afternoon, watching with vigilant and critical eyes every detail of the work of her nurses. In my visits to hospitals in other cities I usually seek out the operating-room nurse, and, if she can spare the time, ask her many questions in regard to the surgical technic. From a seat in the clinical amphitheatre during a series of operations one can also gain a very fair idea of the care and thoroughness with which the nurses have been taught. I will mention some of the weak links in the chain of surgical technic as they have come to my notice in different hospitals, and the fact to be kept in mind is that any one of these weak links is capable of causing a complete breakdown in our surgical asepsis and result in the failure of our efforts to secure clean primary healing of our operation wounds. Of what use is it to insist our surgical staff, both doctors and on nurses, wearing mouth-guards, when it is possible to point out faults in the technic by which septic virus may be carried from an infected case to a clean one? First, then, we will consider the guttapercha gloves. As the gloves can be the gloves can be sterilized absolutely, it is a good thing to use them. But the most important function of the rubber gloves is to prevent the skin of our hands from being infected with the highly tenacious poison of a septic case, as the skin of our own hands when so contaminated cannot be rendered clean for a clean operation which is to follow. A doctor or a nurse may carry this infection on the hands for several days in spite of all efforts to disinfect them. And it is most important that the hands and forearms of the surgeon and his staff of assistants should at all times be protected from contact with septic material. The preparation of the rubber gloves, therefore, is a matter of the most vital moment. Beginning, then, with a pair of gloves which have been worn during a septic operation-which might have been a ruptured appendix and local peritonitis, an empyema of the gall-bladder or of the thorax, a pyosalpinx, or a dermoid cyst, drainage of an infected knee-joint or opening the thigh-bone for acute osteomyelitis, puerperal sepsis and many other conditions. Poison of this character may remain potent for many days upon rubber gloves, basins, table tops and the like. The infected gloves are washed with soap and water by a nurse who perhaps is handling them with her bare hands. Her hands, therefore, become the carriers of infection, and, even though she may not be assisting at operations, she may have a good deal to do with making the necessary preparations for an operation. In some hospitals the nursing staff apparently has implicit faith in the autoclave. The nurses believe-and it is difficult to convince them to the contrary-that everything that comes out of an autoclave must be sterile because it has been exposed to live steam for twenty minutes or a half hour. But the autoclave is fallible. There is a serious and inexplicable inconsistency about the use of the autoclave. The gauze and cotton which come to the hospital from mills or factories, where it is most unlikely they could have become contaminated by any really virulent organisms-probably nothing more than the ordinary dust of a workroom, which is relatively harmlessare put into the autoclave for a half hour on three successive days in order to destroy all germs and spores. The most harmless of all the materials used at the operation are subjected to the most rigid and thorough sterilisation. The live steam under twenty pounds pressure penetrates every portion of the cotton, gauze, bandages, sheets, towels, gowns, etc. And now as to the rubber glove. It is probably capable of greater harm than any other article which is used at the operation. Operating-room nurses have sometimes told me that they depend upon the autoclave to sterilise the gloves. If the gloves have been used in a septic case they are sterilised for twenty minutes, and if they have been used in a clean case they are sterilised for ten minutes. How the nurse knows whether a case is a clean or a septic one I do not know, because it sometimes happens that the operator himself does not know, and only a laboratory report by the bacteriologist can decide the point. When the nurse is asked why the gloves used in a clean case are sterilised only ten minutes instead of twenty, she replies that the longer exposure to the live steam is harmful to the rubber-that it shortens the life of the glove. She admits that the twenty-minute period is desirable for the septic gloves, but she does not and cannot know whether the gloves are septic or not in some cases. The gutta-percha is impervious to steam. The gloves are sometimes folded twice upon themselves and bound up in a small muslin package and a pile of these are packed into the autoclave. Now it is entirely probable that the live steam reaches all the parts of the outer surface of the glove, but I believe there are air pockets inside the glove-probably in the fingers or thumbs-which the steam never reaches. These air pockets therefore permit only dry heat sterilisation instead of moist heat sterilisation for twenty minutes. And the nurse knows that she is dealing with a glove which has been used in a case which was frankly a septic one. She runs her autoclave at about twenty pounds pressure. This provides a temperature of approximately 260° in the sterilising chamber. This is moist heat sterilisation. When the water cools, the nurse, wearing sterile gloves, removes them, dries them. with a sterile towel, powders them inside. and out with sterile talcum powder and folds back the gauntlet. Into this she tucks loosely a small gauze pad covered with talcum powder which the surgeon uses for dusting his hands. The gloves are then placed without folding in a muslin cover and put into a large glass jar. The final preparation is just before they are needed for an operation. The muslin packets are placed full length in the autoclave, lying loosely in rows, not packed together in compact bundles, and sterilized for twenty minutes. The steam easily reaches every part of the glove and the absolute confidence in these gloves-there is no possibility of their carrying septic material from a previous operation. We know that boiling water (210° F.) dusting powder also. The surgeon can have will destroy all organisms and their spores, in five minutes. The nurse therefore be lieves she has a wide margin of safety. But she overlooks the air pockets inside the gloves. These are receiving only dry heat. In order to destroy all germs and their spores by dry heat an exposure of about one hour at a temperature of 350° F. is required. The autoclave falls short of this by nearly 100° in temperature and forty minutes in time. The surgeon, on putting on his gloves, may find when he opens the package that he has two rights or two lefts through an oversight on the part of the nurse who prepared them, and proceeds to reverse one of them, thus bringing the surface of the glove which may not be sterile outside, in contact with the operation field. Or, during the operation the finger of the glove may be punctured or torn and the result may be the same. In order to avoid all possibility of doubt as to the glove being sterile, we have the nurse wash the gloves with soap and water, turning them inside out while doing so. They are then filled with water to remove the air and immersed under the surface of the boiling water and held down by a piece of wire screen so that they cannot float up to the top and be exposed to the air. They are boiled five minutes by the clock. There is another object which may be a carrier of a deadly virus and that is the sand pillow. It usually has a rubber or mackintosh cover. When it is used in a septic operation—as in an acute osteomyelitis or the drainage of an infected joint or necrosis of bone-the discharges from the wound soak through the sheets or towels and soil the sand pillow. The stains are wiped off with a wet cloth later before the nurse puts it away upon a shelf, but no attempt is made to sterilise it. Within a day or two the pillow may be called for again. This time the surgeon is going to remove a bone graft from the tibia to be inserted in the spine, or he finds it a convenient support in doing an arthrodesis on the foot. The most rigid asepsis is required. A nurse brings in the sand pillow, the surgical nurse wraps a sterile cloth about it and it is placed under the patient's limb. So long as the sterile cloth remains dry no harm results. But it does not remain dry. Blood may run down upon it from the wound, or wet gauze sponges come in contact with it, instruments which have been rinsed in the basin of sterile water may be placed upon it, the surgeon washes his gloved hands in the sterile water and returns to the operation with his gloves dripping, and so the coverings of the sand pillow become wet. It is then only a matter of five or ten seconds before the operation field becomes contaminated with the poison of the septic case of the day before. I usually demonstrate this to my class of students by making a red ink stain on the sand pillow and allowing it to dry. The pillow is then covered with a white cloth and a wet gauze sponge is dropped upon it. In from five to ten seconds the red stain is seen coming through and by the end of two minutes the surrounding areas are red and the gauze sponge stained through and through, although it is fourteen layers of gauze in thickness. The demonstration is very simple and absolutely convincing. This same principle applies, of course, to the tops of the tables upon which the instruments are placed and also the top of the operating table. Very often this latter is covered with a rubber pad and this in turn with a clean sheet. If the operation happens to be upon a patient's lower limb, the limb ist painted with a 3 per cent. solution of iodine. while an assistant holds it up with a sterile towel. Then the surgical nurse covers the operating table with a sterile cloth-probably folded to make it double thicknessand the limb is put down upon it. If the rubber pad has been soiled from the discharges of a septic case, our clean operation will almost certainly be infected as soon as the table coverings get wet. When one considers the character of the operative cases which come and go in the general routine of the operating room of a large general hospital, the great care which must be exercised by the nursing staff must be apparent. In a single week there may be a series of operations which includes an operation for gall-stone complicated by an acute septic cholecystitis, the removal of a pyosalpinx, removal of a papillomatous ovarian cyst or a dermoid cyst, a child with ruptured appendix and acute peritonitis, a child with mastoid abscess, another with empyema, and many other similar cases, and all along the clean cases are being operated upon. It is an advantage to have one operating room set apart for septic cases, but even this does not overcome the difficulty. However, the measures to avoid carrying infection from one case to another are simple. There should be a rubber cover provided for each table. They should be sterilised just as the gloves are. The rubber cover is in turn covered with a sterile cloth. The same is true for the sand pillow. The operating table may be covered with a sterile folded. blanket, and on top of this the sterile sheet folded double. Or a sterile rubber cover may be placed over that part of the operating table which is in the neighborhood of the operation, and upon this the sterile folded sheet. The same procedure is followed for each operation. The instruments are sterilised for ten minutes by boiling them in water to which a tablespoonful of carbonate of soda has been added. Only the instruments which will be required for the operation should be prepared. It is a disadvantage to sterilise a large number of instruments which are not likely to be used. They unnecessarily complicate the use of the instrument table, and it is also hard on the instruments. The knives are not boiled. After being used they are carefully washed before being put away. They are sterilised for operation by immersion for twenty minutes in a 1-20 carbolic solution of 3 per cent. formalin. They are removed by a sterile forceps to a tray of 85 per cent. alcohol. This seems to be a safer plan than to depend upon the alcohol tray alone, and particularly if the knife has been used previously in a septic operation. Silk may be prepared by boiling it for ten minutes in a 1-1000 bichloride solution and then for ten minutes in plain water. If the silk is boiled, with the instruments to |