Edwin J. Pulaski

Application of the technology of the germfree laboratory to special problems of patient care

Abstract Studies of the application of germfree technology to special problems of clinical care of patients have been carried out since 1958. Two basic isolator systems have been developed: the surgical isolator system for operating room use and the patient isolator system for ward use. The intent of the surgical isolator system is to provide a controlled environment wherein surgery can be performed in an environment free of exogenous microorganisms. Exclusion of the wound from the ordinary environment of the operating room is accomplished by operating through a sterile flexible disposable plastic chamber, glued aseptically to the surgically prepared skin. Accordingly, only the specific site of operation, the necessary surgical equipment and supplies and the gloved hands of the surgical team are in direct contact with the wound and the sterile interior of the isolator which is inflated by air sterilized by passage through a fiberglass filter similar to the type used in germfree animal isolators. The temperature, humidity and flow of this air is regulated. The rest of the patient, surgical team, supporting tables and room air are outside the isolator and thus effectively separated from the internal environment. Several different types of isolators have been designed for performing various types of operations. These range from compact gauntlet isolators for fairly simple operative procedures to helmet-jacket isolators for more complicated procedures. In the helmet-jacket isolators, the surgeon, assistants and scrub nurse are in helmet-jacket combinations attached to the wall of the isolator to provide free and easy movement of the operating team. The anesthetist is outside the isolator, has ready access to the patient and has an unimpaired view of the operative field. This technic has no effect on microbes present in the patient, such as those in his intestines, but it does allow control of environmental microorganisms and the humidity and temperature to which operative areas are exposed. The extensive experience with animals and limited experience with patients supports this view. The second isolator system is an attempt to devise not only a practical solution to the problem of protecting those patients highly susceptible to infections, but also a means of preventing cross-contamination when infections already exist by effectively isolating patients with serious infections. In this system, the patient, or part of the patient, is contained within the isolator and therefore separated from the medical and para-medical staff, visitors, other patients and the like. The types of isolators used will range from simple gloved bags which may be used to protect areas of limited extent to whole-body and room isolators in which patients may be maintained and treated for long periods. These technics make possible control of not only the microbes in the environment but also the temperature and humidity, factors of significance for certain types of patients. Development of patient and surgical isolators will lay the basis for radically different concepts in hospital design.

The treatment of venous thrombosis with heparin.

tively, 10 per cent expired and pulmonary embolism developed in 28 per cent; whereas in those who were treated with anticoagulants, 0.5 per cent expired and pulmonary embolism developed in 1.4 per cent (1). In 1946, Zilliacus (2) studied the late sequelae of 602 postthrombotic patients. He found that when the initial thrombosis had extended to the thigh, the incidence of late disability was extremely high, and that there was little difference in patients treated by bed rest alone and patients treated with anticoagulants. Patients in whom the thrombosis was limited to the calf showed marked late disability when treated by bed rest; however, in patients who had calf thromboses and who were treated with anticoagulants there was a low incidence of disability. In a ten year follow-up examination of 100 patients who had a history of deep seated thrombosis without treatment, Bauer (3) noted that in 90 per cent, indurative changes were evident and, in 80 per cent, ulcers were present. He emphasized the necessity for early detection of thrombosis while it was still limited to the lower portion of the leg, and for the institution of treatment before the process progressed to the common femoral vein. These statistics emphasize the importance of early recognition and treatment of venous thrombosis if pulmonary embolism and postthrombotic insufficiency are to be prevented. During the past several years, a large volume of medical literature on the treatment of thromboembolism has accumulated. In many papers, conflicting findings and conclusions have been presented. It is not surprising that there are differences of opinion among the leading investigators in a field that is so dynamic and in which so many fundamental mechanisms are as yet not fully understood. It would be futile to attempt to cover the statistical reviews of different types of therapy or to discuss the many divergent views of various investigators. In this paper we will outline our present views concerning the diagnosis and various methods of treatment, and summarize our recent investigative studies with heparin in the treatment of deep venous thrombosis.

Healing of incisions closed with surgical adhesive tape

Abstract 1. 1. Dorsal skin incisions in two groups of guinea pigs were closed with tape and with stainless steel sutures. Animals were sacrificed at fourteen days and wounds studied grossly, histologically and physically. 2. 2. Technical problems of evaluating tapeclosure in animals compromise the decisiveness of any such study. In seventeen of thirty incisions closed with tape, tape-loss and wound disruption occurred within the first forty-eight hours. 3. 3. Thirteen of thirty tape-closed wounds displayed primary healing. In such wounds there were no significant differences between the two groups in wound thickness, breaking strength or tensile strength. Wounds closed with tape or suture were grossly indistinguishable from each other at fourteen days.

Effects of adrenoxyl on blood coagulation mechanism and vasomotor response.

Conclusions 1. Under the stated experimental conditions Adrenoxyl does not influence (a) the speed of the coagulation process, and, (b) the vasomotor response. 2. The method of bleeding time determination in the experimental animal in our hands does not give conclusive results, therefore we are unable to confirm or deny the findings of Roskam and associates.

Patent omphalomesenteric duct in an adult

Abstract A case of patent omphalomesenteric duct is presented. Infection of the umbilicus with an associated myositis of the para-umbilical area were the presenting symptoms. No symptoms were present previously which should have led one to suspect the existence of a patent omphalomesenteric duct in this individual. By keeping the possibility in mind one can easily determine the presence of a patent duct by the introduction of iodized oil through the umbilicus by means of a catheter and by fluoroscopic observation.

Planned timing in treatment of chronic osteomyelitis under antibiotic control

T HE objective in the treatment of chronic osteomyelitis is the arrest and elimination of active foci with an expectancy of permanent heaIing under a cIosed wound, with the least resuIting deformity in the shortest period of time. To meet this objective we must have comprehensive knowledge of the origin, the processes of destruction, reasons of recurrence and foundation of resistance in order to estabIish principIes for the arrest, control and repair of this condition. incIude preparation of the patient for surgery, eradication of bacteria-Iaden compromised tissue, provision ofadequate bIood supply, reinforcement of bone where necessary to provide a functioning limb and fuIl skin-thickness cover.