Part 18
The next year, 1847, witnessed the introduction of chloroform by Sir James Y. Simpson, of Edinburgh. Until I became acquainted with the striking figures just quoted, I had often wondered at the hospital scene in that most touching story, _Rab and His Friends_, by the late gifted and well-beloved physician, Dr. John Brown, of Edinburgh. Nowadays students do not rush into the surgical amphitheatre when they learn that an operation is to be done, but it is taken as a matter of course, for practically every day many operations are done in most of our large hospitals. But, at the time when Rab’s mistress was operated upon, an operation, as has been stated, was a very rare event. Few had the fortitude to endure its dreadful pangs. Now, thanks to the blessed sleep of anæsthesia, sufferers from even the most dreadful disorders can have long and difficult operations done, accurate and tedious dissections made, and yet feel not a twinge of pain.
Besides general anæsthesia by ether, chloroform, and a few other agents, there have been introduced several means for producing “local anæsthesia,” _i.e._, agents which destroy the sensibility of the part of the body to be operated upon while not producing unconsciousness. Freezing the part by ice and salt, or by a quickly evaporating spray of rhigolene or chloride of ethyl, are sometimes used. But cocaine and a somewhat similar substance, eucaine, have of late been more extensively used on man, after their harmlessness had been first shown by experiments on animals. In 1885 Corning, of New York, injected a solution of cocaine as near to the spinal cord as was possible, and produced insensibility of all the body below the point of injection by the effect of the cocaine upon the spinal cord. A few years ago Quincke, of Kiel, in Germany, devised a means of puncturing the spinal canal itself in the lumbar region (the lowest part of the small of the back) for the purpose of drawing off some of the fluid for examination. This suggested to Bier, then of Kiel, who was apparently ignorant of Corning’s work, that cocaine could be injected through a hollow needle inserted into the spinal canal by “lumbar puncture” and so produce anæsthesia of all the body below this point. This method was published by him in 1899, and was soon repeated in America. In France, however, it has been practised more than elsewhere, Tupper, of Paris, having successfully done over two hundred operations by “spinal anæsthesia.” All of the body below the diaphragm can thus be deprived of sensibility. The method will probably never replace ether and chloroform, but in many cases is a valuable aid to the surgeon. But it has its dangers and its inconveniences. The ideal anæsthetic is not that which destroys sensibility and yet leaves the patient perfectly conscious, as spinal anæsthesia does. A patient to whom I recently proposed it for certain special reasons rejected it, saying, with probable truth, that she could never bear the strain of lying on the table perfectly conscious of all that was being done and frightened by any surgical emergency which might easily arise in such a long, difficult, and dangerous operation. The ideal anæsthetic is that which will abolish pain and consciousness without danger to life. The twentieth century will undoubtedly see the discovery of this safe and efficient anæsthetic.
ANTISEPSIS
But the limits of surgical progress were not yet reached. Let me quote again from the address before alluded to:
“Even the introduction of anæsthesia, however, did not rid surgery of all its terrors. The acute pain of the operation was abolished, but the after-suffering, as I know only too well, in my early surgical days, was something dreadful to see. The parched lips of the poor sufferer, tossing uneasily during sleepless nights; wounds reeking with pus, and patients dying by scores from blood-poisoning, from erysipelas, from tetanus, from gangrene, were only too familiar sights in the pre-antiseptic days. Then, again, there arose one of these deliverers of the human race whose name can never be forgotten and whose fame will last so long as time shall endure. Jenner, Warren, and Lister are a triumvirate of names of which any profession may well be proud. Thank God, they all sprang from virile Anglo-Saxon loins! No praise, no reward, no fame is too great for them. That Lord Lister still lives to see the triumph of his marvellous services to humanity is a joy to all of us. And when the profession arose _en masse_, within the last few years, at the International Congress of Berlin, and at the meeting of the British Medical Association in Montreal, and welcomed him with cheer after cheer, it was but a feeble expression of gratitude for benefits which no words can express.
“Before Lister’s day erysipelas, tetanus, gangrene, and blood-poisoning in its various phases were the constant attendant of every surgeon. They were dreaded guests at almost any operation; and when in rare cases we obtained primary union without a drop of pus, without fever, and with but little suffering, it was a marvellous achievement. Now it is precisely reversed. The surgeon who does not get primary union without a drop of pus, with no fever, and with little suffering, asks himself—what was the fault in my technic? To open the head, the abdomen, or the chest thirty years ago was almost equivalent to signing the death-warrant of a patient. The early mortality of ovariotomy was about sixty per cent.; two out of three died. Now many a surgeon can point to a series of one hundred abdominal operations with a fatality of only two or three per cent. When Sir Spencer Wells recorded his first one thousand cases of ovariotomy it was calculated that after deducting the years which the patients who died from the operation would have lived had no operation been done the net result of the thousand cases was an addition of twenty thousand years to human life. One thousand ovariotomies under antiseptic precautions at the present would certainly add at least thirty thousand years to human life. Would not such a guerdon be enough for any man?
“This, too, is a direct result of laborious laboratory researches, beginning with the investigations of Liebig and Pasteur on fermentation. Lister went still further. Even before the discovery of the bacteria of suppuration, of tetanus, and of erysipelas he showed us experimentally how, by surgical cleanliness, we could avoid all infection and so banish these pests from our hospitals and bring life and health to many who otherwise would have perished from operations which are now perfectly safe.
“The mortality of compound fractures in the pre-antiseptic days was about sixty per cent. It was one of the most dreaded of all accidents. Its mortality now is perhaps not over three per cent., and the mortality from sepsis after such a fracture, in the hands of well-instructed surgeons, is almost nil. Prior to Lister’s day the mortality of major amputations varied from fifty to sixty-three per cent. Now it is from ten to twenty per cent. And so I might go on with operation after operation and show how they have become so safe that one need not dread any, saving exceptional cases.
“These two modern discoveries, anæsthesia and antisepsis, have utterly revolutionized modern surgery. They have made possible operations which, by reason of their length and pain and danger, were utterly unjustifiable in former days, but are now the daily occupation of a busy surgeon. And, far better than this, they have enabled us to bring to homes and hearts, which otherwise would have been broken up and wrung with sorrow, the comfort of life restored to dear ones upon whom depended the happiness and support of the families. Translate figures into happy hearts and prosperous homes if you can, and then you can tell me what Warren and Lister have done for humanity!”
The result of these two wonderful discoveries has been to separate us from the surgical past, as by a great gulf.
“Great theologians, such as a Calvin or a Jonathan Edwards, were they recalled to life, could discourse as learnedly as ever of predestination and free will; great preachers, as a Beecher or a Spurgeon, could stir our souls and warm our hearts as of old; great jurists, as a Justinian or a Marshall, could expound the same principles of law which hold good for all time; great forensic orators, as a Burke or a Webster, could convince us by the same arguments and arouse us by the same invectives or the same eloquence that made our fathers willing captives to their silver tongues. But to-day, so rapid has been our surgical progress, a Velpeau, a Sir William Ferguson, or a Pancoast, all of whom have died within the last thirty years, could not teach modern surgical principles nor perform a modern surgical operation. Even our every-day surgical vocabulary—staphylococcus, streptococcus, infection, immunity, antisepsis and asepsis, toxin and antitoxin—would be unintelligible jargon to him; and our modern operations on the brain, the chest, the abdomen, and the pelvis would make him wonder whether we had not lost our senses, until, seeing the almost uniform and almost painless recoveries, he would thank God for the magnificent progress of the last half-century, which had vouchsafed such magical, nay, such almost divine, power to the modern surgeon.”
THE SURGERY OF WAR
One of the immediate consequences of the introduction of the antiseptic method has been a remarkable mitigation of the horrors of war. Our recent war with Spain has proved, and the present military operations in the Philippines and of the British in South Africa will still further prove, its advantages. Witness a little book written by Professor von Esmarch, of Kiel, Germany, with the apt title, _The Fight of Humanity Against the Horrors of War_; with an appendix, entitled, “The Samaritan on the Battle-field.” One of the most valuable means for the preservation of human life is carried by every soldier in a modern civilized army as a part of his regulation outfit, a “First Aid Package” for the treatment of any wound or injury; and one of the most valuable and interesting papers read before the American Surgical Association, at its meeting in Chicago in 1899, was by Professor Senn on the “First Aid Package.” This first aid package contains an antiseptic dressing, which can be applied to all but the gravest wounds for the purpose of preventing infection, which is the principal danger to life after accident or injury. The universal testimony of our surgeons in Cuba was that by its use most wounds were prevented from becoming infected, and, therefore, inflamed, and that the number of operations was greatly diminished by reason of its use.
BACTERIOLOGY
In experimental science, two methods of progress are observed; first, in actual practice certain methods are adopted because they are found to be the most advantageous and useful, though we cannot explain why it is so—_i.e._, practice outstrips theory. Again, as a result of experimental investigation, certain facts are discovered which explain why the practical methods just alluded to are the best, and this in turn suggests further improvements in our practice—_i.e._, theory outstrips practice and enlarges its domain. Thus outstripping theory, the practical advance made by Lister was an example of the first. His striking results in turn stimulated scientific observers to make new discoveries of the greatest importance, and thus science immensely improved and widened our practical methods.
No definite year or day can be assigned as the birth-date of Lord Lister’s antiseptic methods, as we can, for instance, for vaccination or for anæsthesia. We may assume, at least for this country, the summer of 1876 as the starting-point. During that year Lord Lister attended the International Medical Congress held in Philadelphia, and demonstrated his then methods and convinced a few surgeons of their immense advantages. Even before that date there had been very many experiments and observations, especially on the blood. In 1863 Davaine, in France, had discovered little rod-like bodies in the blood in wool-sorters’ disease, or anthrax, which he named from their shape “bacteria,” or “little rods.” This name has been adopted for all forms of germs, though many of them are not rod-like in their shape. Not until 1881 was the cause of inflammation and suppuration (the formation of pus or “matter”) discovered. In that year Ogston, of Aberdeen, published experiments which he believed demonstrated the fact that certain bacteria were the cause of suppuration. Since then this has been amply confirmed not only by experiments upon animals, but by observation in man. In 1882 Robert Koch, of Berlin, discovered the cause of tuberculosis, a little rod-like body, which is named the “bacillus” of tuberculosis. In 1883 Fehleisen discovered the germ of erysipelas, and in 1887 Nicolaier and Rosenbaum discovered the bacillus of tetanus or lockjaw. So recent have been the discoveries in bacteriology which have led to vast improvements in our methods of treatment of wounds and the performance of operations.
While the principles established by Lord Lister have remained unchanged, the details in the treatment have been greatly simplified and made more efficient. For the information of the general reader, let me state a few facts. Bacteria are divided into two principal classes, in accordance with their form. One, known as “cocci,” from the Greek word coccus—“berry”—may be likened to billiard-balls. Some of these occur in bunches, which have been likened to bunches of grapes, and hence are called, again from a Greek term, “staphylococci.” Others are arranged in chains, like beads, and are called “streptococci.” These last are very much more virulent and dangerous than the staphylococci. Both of these produce pus or matter, and they are the most widely diffused and most common forms found in infected or suppurating wounds. One form is the cause of erysipelas. A second form, known as “bacilli,” may be likened to a lead-pencil. Among the various bacilli that have been discovered are those of tuberculosis, glanders, tetanus or lockjaw, etc. I omit many others found in medical disorders, as they do not concern this paper. How important these discoveries are may be seen by the following facts: Tuberculosis, next to that of suppuration, is, perhaps, the most widely extended infection to which man, as well as animals, is liable. We are all familiar with it in the form of “consumption,” but the non-medical reader is, perhaps, not aware of the fact that it affects not only the lungs, but also the bowels in consumption of the bowels; the bones, as is seen by every surgeon almost daily, and especially as the cause of the crooked backs seen in spine diseases; in the joints, as is seen in hip-joint disease, white swelling of the knee, ankle-joint disease, and similar disease of all the other large joints of the body; in the brain, in tubercular meningitis; in the abdominal cavity, in tubercular peritonitis; in the skin, in certain forms of ulceration, commonly called lupus; in the glands, as in the swollen glands, or “bunches,” in the neck, and endless other varieties which I need not name.
The bacillus of lockjaw is found in great abundance around stables, and this explains the fact that hostlers, drivers, cavalrymen, all of whom had to do with horses, are especially liable to attacks of lockjaw. Moreover, certain bacteria thrive best when exposed to the open air. Other bacteria, and among them the bacilli of lockjaw, thrive best when the air is excluded, and this explains the danger of treading on a rusty nail, which is popularly and rightly known as peculiarly liable to produce lockjaw. The reason is not because it is a nail, nor because it is old, nor because it is rusty, but because from the earth in which it lies it is most apt to be the means of introducing into a punctured wound the bacilli of lockjaw. Such a wound bleeds but very little, the blood soon crusts and excludes the air, and if any of the bacilli of lockjaw have been carried into the body, they find in such a closed wound, from which the air is excluded, the most favorable conditions for growth and infection of the whole body. Knowing these facts from experiment, the treatment is clear. Lay open such a wound and disinfect it.
These two forms, the “cocci,” or berry-like bacteria, and the “bacilli,” or rod-like bacteria, comprise the great majority of dangerous bacteria.
It must be remembered that there is an enormous number of bacteria which are not dangerous; some of them are entirely harmless even if introduced into the human body. Others are the bacteria of decomposition, or putrefaction, which are known as “saprophytic” bacteria. All of the harmless ones are known as “non-pathogenic,” that is, non-producers of disease. Those which produce disease are known as “pathogenic,” and those which produce suppuration as “pyogenic” or pus-producing bacteria.
All of these bacteria are plants, and not, as is very frequently supposed, animals of a low form. The danger from their introduction into the body can be best appreciated, perhaps, by the statement of Belfield, who estimated that a single bacterium which weighs, approximately, only the 1-40,000,000 part of a grain, if given plenty of food and plenty of “elbow room,” would so rapidly develop that in three days it would form a mass weighing 800 tons! It is the old story of the blacksmith who was to get a penny for the first nail, two for the second, four for the third, and so on till a set of shoes would cost more than Crœsus could pay for.
The effect of the bacteria has been determined by experiment to be proportionate to the dose. A cubic centimetre is a cube two-fifths of an inch on each side. One-tenth of such a cube of pure culture of one bacterium (_Proteus vulgaris_) contains 225,000,000 bacteria, and if injected under the skin of a rabbit will produce death. Less than 18,000,000 will produce no effect whatever. Of one kind of staphylococcus, if 250,000,000 are introduced under the skin of a rabbit there will be produced a small abscess, but it requires 1,000,000,000 to produce speedy death. On the other hand, of the bacillus of lockjaw it requires only 1000 to produce death, so virulent is this germ.
Moreover, their effect on tissues and persons in different states varies very much. Thus, it is found that when a certain number of bacteria are injected into the cavity of the abdomen of an animal, if the animal is healthy and the peritoneum (the thin lining membrane of the abdomen) is healthy, the animal will recover perfectly well; but if the peritoneum be scraped and torn (and it must be remembered that the healthy peritoneum is devoid of sensation), that the same dose which before was harmless will now produce a violent peritonitis and very likely death. The practical lesson from this experiment upon animals is very evident. Every surgeon who opens the abdomen is most careful, if possible, not to injure the peritoneum, but manipulates with the greatest care lest fatal results follow any serious injury to that membrane. So, too, if the general health be impaired, it is found that an injection from which a healthy animal would recover will be followed by fatal consequences if the general health is below par. Again, if an animal has a simple fracture of his thigh-bone, and that is the only injury that he receives, no infection from the exterior having occurred, he will make a good recovery; but if at the same time he receives a lacerated wound, it may be even in another part of the body, and this wound, not being cared for most scrupulously, becomes infected, the infection will fasten on the distant spot of least resistance, the broken thigh-bone, and will produce a most dangerous and very frequently fatal form of inflammation.
I need scarcely point out in this connection, as in fact throughout this entire consideration of bacteriology, how important a part in its development has been played by experiment upon animals. The experimental facts just stated are of vital importance in the treatment of surgical diseases, and evidently could not have been determined upon mankind. It is not too much to say that had vivisection been restricted or prohibited the surgery of to-day would be the barbarous surgery of thirty years ago.
Even granting that an enormous number of the bacteria are harmless, the wonder is that with so many foes on every hand we live an ordinary lifetime. Fortunately, however, in the human body there is not only a lack of food sufficient and “elbow room” enough for them to work their dire effects, but there is that which “makes for righteousness” in our physical organization as well as in our souls.
The moment that bacteria are introduced into the human body a certain number of cells hasten to destroy them. These are called “phagocytes” or devouring cells, because they eat up the bacteria. Whether the patient survives or dies depends on whether the bacteria get the upper hand of the phagocytes or the phagocytes the upper hand of the bacteria.
These statements are very easy to make, but the results have only been obtained by prolonged and laborious investigations in the laboratory and by experiments upon animals which have demonstrated these facts.
The bacteria are recognized by various methods: First, by form. Many which are identical in appearance, however, differ greatly in effects. A handful of turnip-seed and a handful of rape-seed look very much alike, but if they are planted the plants differ so greatly that we can recognize the difference in the seed by the difference in the crop; hence the second method of recognizing differences in bacteria is by planting them. Different methods have been practised. Some are sown on the raw surface of a potato; others on bread paste; others in certain jelly-like materials, such as gelatine or agar-agar. It was soon found as a result of these experiments that the bacteria flourished best, some in one soil, some in another. Again, the crops of mould which come from them differ greatly in color, some being black, some red, some white, some yellow, etc. A third method also is by staining them with various dyes, when it is found that some bacteria will take one stain best, others will take another, and so on through the whole list.