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CLEAN HANDS
1292 G.c.E. at ordinary level in physics, in addition to the subjects stipulated by this society. Council’s decision reflected the belief that, in making mathematics, rather than physics, the compulsory subject, the possibility of training would be extended to young people whose previous education had not been specifically oriented towards a scientific career. It is usually feasible for those applicants who " have all the qualities of good radiographers but have not passed mathematics at ordinary level in the G.c.E. to obtain this last requirement by evening courses at a technical college. To ask them to do this is not necessarily to lose them to the profession. I have known several who by a little application and persistence have successfully qualified for training.
in the
"
Professor Johnstone says that in Sweden there is a " trend to do away with technical assistance ", and that Great Britain will follow the Continental lead. A rather different picture is provided by the formation of the International Secretariat of Radiographers and Radiological Technicians during the ninth International Congress of Radiology, held at Munich in 1959. We know that the countries of Western Europe are at present concerned to improve their standard of training for radiographers. It was clear to the British representatives at the congress that the level which is sought by our European colleagues is that established in this country by the Society of Radiographers. It would appear to be of more than national significance that that standard should be maintained. Society of Radiographers, D. N. CHESNEY London, W.1. President.
CLEAN HANDS
SIR,- The preparation of the surgeon’s hands for operating is very important both for the patient and for the surgeon. It is also of some economic interest. The present practice of scrubbing for 5-15 minutes is tradition rather than any more compelling reason. Some surgeons consider that the preoperative cleansing of hands should render them sterile; and on this premise are quite prepared to touch the outside of the gown, and even gloves as they put them on. Others consider the hands to be clean but not sterile, and therefore take great care to avoid touching anything sterile with their hands, and also to keep their gloves intact during the operation. Some surgeons scrub with equal care between each operation, while others scrub once or twice during a morning’s operating-list, and otherwise rely on changing their gloves. Some solution applied to the hands between glove changes sometimes supplements the security. Many solutions are used for this purpose. Presumably the object is to render the hands and forearms free from bacteria for the longest time in the simplest and most economical way which has no ill effect on the surgeon or his hands. To improve skin preparation it was decided in 1956 to prepare the patients’ skin preoperatively not with 2% iodine in spirit, as hitherto, but with a 0-05% solution of chlorhexidine (’Hibitane’) in spirit. A limited number of swabs (about 40 in all) was taken of the skin during, and at the end of, operation. No pathogenic organism was grown from any of these-the longest period of test was 2 hours. More exhaustive bacteriological tests of the skin at operation, as were done for iodine (reported by Gardner12), were not thought necessary. This solution in well over 1000 cases has given rise to no skin reactions and no evidence has been found that the solution was in any way less suitable or reliable than iodine. The satisfactory results obtained on skin preoperatively led us to test a similar solution for preparing hands before operation. Our group pharmacist and the makers (Imperial Chemical Pharmaceuticals) recommended a solution of
perhaps based
1. 2.
on
Gardner, A. D., Seddon, H. J. Lancet, 1946, i, 683. Gardner, A. D. ibid. 1948, ii, 760.
0-5% cetrimide (’ Cetavlon ’) and 0-05% chlorhexidine in 70% advised that thorough exposure of socially this solution for ten seconds would ensure that they were free from organisms. During the past year all the nursing staff and surgeons undertaking my lists and emergency procedures have prepared their hands in this way. When this method was first brought into use broth cultures were taken on twelve occasions from the hands of 14 of those working in the theatre; and 153 cultures were made. These cultures were taken from dry, " " socially clean hands before immersion in the solution; after immersion for twenty seconds in the solution; and after gloves were removed at the end of the operation. The timeinterval between these last two swabs was carefully adhered to at first, but as it was always well within the five hours recommended by the manufacturers and the pattern of results was so similar, the timing was given up. After chlorhexidine 77-8% of the cultures grew no organisms, 16-6% grew non-pathogenic micrococci, and 5-6% aerobic spore-bearing bacilli. Organisms present on the hands before immersion in the solution included Staphylococcus aureus, Streptococcus viridans. Str. haemolyticus, Proteus vulgaris, and paracolon bacteria. These never appeared in the cultures taken after immersion in the solution or when gloves were removed after operation, but micrococci usually grew in cultures taken after gloves were removed. On a few occasions aerobic spore-bearers-but no pathogenic organisms-were grown. No member of the staff has shown sensitivity to the solution, or irritation from it. The patients operated on under this regimen have been carefully watched for evidence of infection. This has been difficult to assess. Some operations were to reopen old wounds and compound fractures, others were on fresh wounds. There has been no evidence to suggest that the change has had anything but a good effect on our already low infection-rate.
spirit. We
were
clean hands and
arms to
It is
interesting to speculate on the number of surgical man-hours per week in this country devoted to the ritual of scrubbing-up. If this could be replaced by a technique affording greater protection for the patient, and taking one-tenth of the time, all concerned would obviously benefit. There may be other solutions which will do the job equally well; but the solution we have "
"
tried has
met
in all respects the demands made
on
it.
I wish to thank Dr. R. L. Vollum and Dr. W. H. H. Jebb, of the department of bacteriology, for their help in the bacteriological investigations and in interpreting the results. Accident Service, Radcliffe Infirmary, Oxford.
J. C. SCOTT.
CHELATING AGENTS AND ZINC EXCRETION
SIR, The hypocholesterolasmic action of aspirin has recently been discussed.1-4 A similar reduction in serum-cholesterol has been reported in patients following treatment with the disodium5 and calcium 6salts of ethylenediamine tetra-acetic acid, penicillamine,8 isoniazid,9 British anti-Lewisite (B.A.L.),10 hydralazine,’ cliphenylthiocarbazone,"’ and neomycin.12 A property common to all of these structurally dissimilar 1. Hetzel, B. S., Charnock, J. S., Lander, H. Metabolism, 1959, 8, 205. 2. Reid, J. Med. Trib. 1960, 1, 20. 3. Eidlitz, M. Lancet, 1960, ii, 1123. 4. Alexander, W. D., Macdougall, A. I., Oliver, M. F., Boyd, G. S. ibid. p. 1399. 5.
6. 7. 8. 9.
10. 11. 12.
Clarke, N. E., Sr., Clarke, N. E., Jr., Mosher, R. E. Amer. J. med. Sci. 1960, 239, 732. Perry, H. M., Jr.., Schroeder, H. A. J. chron. Dis. 1955, 2, 520 1452. Perry, H. M., Jr., Perry, E. F.I.J.inclin. Invest. 1959,in38,Medicine Scheinberg, I. H., Sternlieb, Metal-Binding (edited by M. J. Seven); p. 275. Philadelphia, 1960. Ostrovskii, I. M., Kagan, D. Z., Iaroshevich, A. A. Bull. Biol. Med. Exp., U.S.S.R. 1958, 45, 551. Bobadilla, R. E. An. Fac. Farm., Lima, 1952, 3, 197. Lo, M. Canad. med. Ass. J. 1960, 82, 1203. Samuel, P. Proc. Soc. exp. Biol., N.Y. 1959, 102, 194.
in the
"
Professor Johnstone says that in Sweden there is a " trend to do away with technical assistance ", and that Great Britain will follow the Continental lead. A rather different picture is provided by the formation of the International Secretariat of Radiographers and Radiological Technicians during the ninth International Congress of Radiology, held at Munich in 1959. We know that the countries of Western Europe are at present concerned to improve their standard of training for radiographers. It was clear to the British representatives at the congress that the level which is sought by our European colleagues is that established in this country by the Society of Radiographers. It would appear to be of more than national significance that that standard should be maintained. Society of Radiographers, D. N. CHESNEY London, W.1. President.
CLEAN HANDS
SIR,- The preparation of the surgeon’s hands for operating is very important both for the patient and for the surgeon. It is also of some economic interest. The present practice of scrubbing for 5-15 minutes is tradition rather than any more compelling reason. Some surgeons consider that the preoperative cleansing of hands should render them sterile; and on this premise are quite prepared to touch the outside of the gown, and even gloves as they put them on. Others consider the hands to be clean but not sterile, and therefore take great care to avoid touching anything sterile with their hands, and also to keep their gloves intact during the operation. Some surgeons scrub with equal care between each operation, while others scrub once or twice during a morning’s operating-list, and otherwise rely on changing their gloves. Some solution applied to the hands between glove changes sometimes supplements the security. Many solutions are used for this purpose. Presumably the object is to render the hands and forearms free from bacteria for the longest time in the simplest and most economical way which has no ill effect on the surgeon or his hands. To improve skin preparation it was decided in 1956 to prepare the patients’ skin preoperatively not with 2% iodine in spirit, as hitherto, but with a 0-05% solution of chlorhexidine (’Hibitane’) in spirit. A limited number of swabs (about 40 in all) was taken of the skin during, and at the end of, operation. No pathogenic organism was grown from any of these-the longest period of test was 2 hours. More exhaustive bacteriological tests of the skin at operation, as were done for iodine (reported by Gardner12), were not thought necessary. This solution in well over 1000 cases has given rise to no skin reactions and no evidence has been found that the solution was in any way less suitable or reliable than iodine. The satisfactory results obtained on skin preoperatively led us to test a similar solution for preparing hands before operation. Our group pharmacist and the makers (Imperial Chemical Pharmaceuticals) recommended a solution of
perhaps based
1. 2.
on
Gardner, A. D., Seddon, H. J. Lancet, 1946, i, 683. Gardner, A. D. ibid. 1948, ii, 760.
0-5% cetrimide (’ Cetavlon ’) and 0-05% chlorhexidine in 70% advised that thorough exposure of socially this solution for ten seconds would ensure that they were free from organisms. During the past year all the nursing staff and surgeons undertaking my lists and emergency procedures have prepared their hands in this way. When this method was first brought into use broth cultures were taken on twelve occasions from the hands of 14 of those working in the theatre; and 153 cultures were made. These cultures were taken from dry, " " socially clean hands before immersion in the solution; after immersion for twenty seconds in the solution; and after gloves were removed at the end of the operation. The timeinterval between these last two swabs was carefully adhered to at first, but as it was always well within the five hours recommended by the manufacturers and the pattern of results was so similar, the timing was given up. After chlorhexidine 77-8% of the cultures grew no organisms, 16-6% grew non-pathogenic micrococci, and 5-6% aerobic spore-bearing bacilli. Organisms present on the hands before immersion in the solution included Staphylococcus aureus, Streptococcus viridans. Str. haemolyticus, Proteus vulgaris, and paracolon bacteria. These never appeared in the cultures taken after immersion in the solution or when gloves were removed after operation, but micrococci usually grew in cultures taken after gloves were removed. On a few occasions aerobic spore-bearers-but no pathogenic organisms-were grown. No member of the staff has shown sensitivity to the solution, or irritation from it. The patients operated on under this regimen have been carefully watched for evidence of infection. This has been difficult to assess. Some operations were to reopen old wounds and compound fractures, others were on fresh wounds. There has been no evidence to suggest that the change has had anything but a good effect on our already low infection-rate.
spirit. We
were
clean hands and
arms to
It is
interesting to speculate on the number of surgical man-hours per week in this country devoted to the ritual of scrubbing-up. If this could be replaced by a technique affording greater protection for the patient, and taking one-tenth of the time, all concerned would obviously benefit. There may be other solutions which will do the job equally well; but the solution we have "
"
tried has
met
in all respects the demands made
on
it.
I wish to thank Dr. R. L. Vollum and Dr. W. H. H. Jebb, of the department of bacteriology, for their help in the bacteriological investigations and in interpreting the results. Accident Service, Radcliffe Infirmary, Oxford.
J. C. SCOTT.
CHELATING AGENTS AND ZINC EXCRETION
SIR, The hypocholesterolasmic action of aspirin has recently been discussed.1-4 A similar reduction in serum-cholesterol has been reported in patients following treatment with the disodium5 and calcium 6salts of ethylenediamine tetra-acetic acid, penicillamine,8 isoniazid,9 British anti-Lewisite (B.A.L.),10 hydralazine,’ cliphenylthiocarbazone,"’ and neomycin.12 A property common to all of these structurally dissimilar 1. Hetzel, B. S., Charnock, J. S., Lander, H. Metabolism, 1959, 8, 205. 2. Reid, J. Med. Trib. 1960, 1, 20. 3. Eidlitz, M. Lancet, 1960, ii, 1123. 4. Alexander, W. D., Macdougall, A. I., Oliver, M. F., Boyd, G. S. ibid. p. 1399. 5.
6. 7. 8. 9.
10. 11. 12.
Clarke, N. E., Sr., Clarke, N. E., Jr., Mosher, R. E. Amer. J. med. Sci. 1960, 239, 732. Perry, H. M., Jr.., Schroeder, H. A. J. chron. Dis. 1955, 2, 520 1452. Perry, H. M., Jr., Perry, E. F.I.J.inclin. Invest. 1959,in38,Medicine Scheinberg, I. H., Sternlieb, Metal-Binding (edited by M. J. Seven); p. 275. Philadelphia, 1960. Ostrovskii, I. M., Kagan, D. Z., Iaroshevich, A. A. Bull. Biol. Med. Exp., U.S.S.R. 1958, 45, 551. Bobadilla, R. E. An. Fac. Farm., Lima, 1952, 3, 197. Lo, M. Canad. med. Ass. J. 1960, 82, 1203. Samuel, P. Proc. Soc. exp. Biol., N.Y. 1959, 102, 194.