Part 19
At first it was thought that these bacteria existed chiefly in the air, and hence in Lister’s early methods powerful spray-producing apparatus were used; but while it is true that they do exist in the air, it is found that this is not the principal source of infection. There is no substance (which has not been disinfected) that is not covered with the germs of these little plants. They exist in our food and drink; but the intestine is, one may say, a natural home in which many exist without harm to the body. For surgical purposes their existence is most important, first, in the earth, where, as I have already shown, the bacillus of lockjaw is most frequently found. So, too, the bacillus of wool-sorters’ disease (_Anthrax_) exists in the earth. If an animal dying of anthrax is buried, worms coming from the carcass up through the ground carry the infection, so that other animals grazing over this surface will become readily infected. The means by which we can avoid infection from the earth is very evident, viz., every person who has been run over by the cars or who has fallen on the ground and broken his leg, etc., must have the wound most carefully cleansed from all dirt. If this is scrupulously done the danger of tetanus or other similar earth-born bacterial disease is almost nothing.
A still greater danger to every patient, however, is found in the clothing, in the skin, and all dressings which are applied to wounds. The skin is full of bacteria of the most dangerous kind; even the spotless hands of the bride, in the eyes of the surgeon, are dirty. No one can touch a wound with ordinarily clean hands without infecting it. All clothing, dressings—_e.g._, lint and soft linen rags, and such like—are full of bacteria of the most dangerous kind. Perhaps the most dangerous place is the space under the nails of the surgeon’s hand, for the mere mechanical removal of any dirt under the nails by cleansing them does not make them clean surgically. The nails must be cut short and prepared in a way I shall mention directly, or they are full of peril to any patient into whose wound a non-disinfected finger is introduced. Again, another source of infection which thirty years ago we never thought of is our instruments. Then instruments were washed with soap and water and were made clean to the eye, but they were still covered with invisible death-dealing bacteria which hid especially in the joints and irregularities of the surface of all instruments.
All of these somewhat detailed statements lead up to a consideration of the difference between the old surgery and the new. Thirty years ago when an operation was to be performed or an accident cared for we laid out our instruments which were visibly clean, used them with hands which were as clean as those of any gentleman, and applied soft linen rags, lint, and other dressings. To-day we know that these apparently clean instruments, hands, and dressings are covered with bacteria, which produce infection, and, therefore, suppuration, and frequently run riot in blood-poisoning, erysipelas, lockjaw, and death.
How does a modern surgeon perform an operation? All bacteria can be killed by heat. Cold has no effect upon them, but the temperature of boiling water (212° Fahr.) is sufficient to destroy them all usually within fifteen or twenty minutes; hence, first, instruments are all boiled; and, secondly, dressings are either steeped in such solutions as have been found to destroy the bacteria, such as carbolic acid or corrosive sublimate, or other preparations, or, still better, are placed in sterilizers, that is to say, metal cylinders, which are then filled with steam, usually under pressure, so as to obtain a temperature of 240° Fahr., and thus make sure of the death of the bacteria. Unfortunately, our hands cannot be boiled or steamed, but the modern surgeon first uses soap and water most vigorously over his hands and arms up to the elbow. The nails are cut short and the scrubbing-brush is especially applied to the nails so as to clean the fingers at the ends. Then by various means, such as pure alcohol, which is one of our best disinfectants, or solutions of corrosive sublimate, and other means too technical to mention, the hands are sterilized. Rubber gloves are frequently used, so as to preclude infection, as they can be steamed to 240° Fahr. Removing at least his outer clothing, the surgeon puts on a cotton gown which has been steamed and so made free from bacteria. Not a few surgeons also wear sterilized caps, so that any bacteria in the hair will not be sifted into a wound, and some wear respirators of sterile gauze over the mouth and beard for the same reason. All the dressings have been sterilized by superheated steam. All the threads by which blood-vessels are tied have been either boiled or otherwise sterilized. All the material for sewing up the wounds, and the needles with which they are sewn, have been similarly disinfected. The skin of the patient is also sterilized, usually the day beforehand, in the same manner in which the surgeon’s hands have been disinfected, and are disinfected a second time just at the moment of the operation. If the case is one of accident, such as a crushed leg from a trolley-car, all of the dirt is most carefully washed away with soap and water, and the parts are disinfected, not only on the exterior, but also by prolonged washing with some cleansing agent in the interior of the wound, the patient being under the influence of ether, of course.
It is easily seen from such a description of a modern operation that no case can receive due care in one of our modern homes, even the best. The facilities do not exist, and hence surgeons are more and more declining to do operations, whether for accident or disease, in private houses, except in a case of absolute necessity, and a happy custom is growing more and more in favor with the community of having all operations and all accidents cared for in a well-equipped hospital.
RESULTS OF MODERN SURGERY
As the result of our ability to perform operations without pain, thanks to anæsthesia, and our ability to perform operations without infection, and, therefore, almost without danger, thanks to antisepsis, the range of modern surgery has been enormously increased. Unless one has lived through the old surgery and into the new he scarcely can appreciate this widening of the field of operative surgery. Thirty years ago, in consequence of the great danger of opening the head, the chest, or the abdomen, or, in fact, of making an incision anywhere about the body, the surgeon never dared to interfere until he was obliged to do so. Hence, not only were many modern operations not even thought of, but in obscure cases we had to wait until time and disease developed symptoms and physical signs such that we were sure of our diagnosis, and then, knowing that death would follow if we did not interfere, we ventured to operate. Now we anticipate such a fatal termination, and in most cases can avert it. In perhaps no class of cases has the benefit of this immunity from infection and danger been shown than in the obscure diseases of the brain and the abdomen. To-day, if we are uncertain as to whether there is serious danger going on which, if unchecked, will result in death, we deliberately open the one cavity or the other, in order to find out the exact state of affairs. Supposing that the mischief is trifling, or even that there is no mischief, we then know how to deal with the symptoms which have been puzzling us. So far as the exploratory operation is concerned, the patient recovers from it in a short time, and, meantime, perhaps has also been cured of the symptoms which were before so ill understood. If any serious disease is found, in the majority of cases we can cope with it successfully. Before the days of antisepsis and anæsthesia the field of operation was greatly restricted, and practically the removal of tumors, amputations, and a few other operations were all that were done. Now all the then inaccessible organs are attacked with an intrepidity born of an assurance of safety. Recovery usually sets the seal of approval on the judgment of the surgeon. Thirty years ago, taking all operations together, fully one-third of our patients died, many of them often from slight operations which were followed by infection. To-day, including even the far more grave operations which are now done, the general mortality will scarcely exceed five per cent., and many surgeons are able, in a series of several hundred operations, to save ninety-seven out of every hundred patients!
SERUM TREATMENT
Another remarkable recent discovery, the result of numerous and careful investigations in the laboratory, is a wholly new means of treatment, viz., that method which is known as orrhotherapy, or serumtherapy, or the treatment by injecting certain antitoxins under the skin by a hypodermatic syringe. It would lead me too far to enter into the theory upon which these were first used. Suffice it to say that in the blood of an animal that has passed through a certain disorder the liquid part of the blood contains an antidote or antitoxin. If a certain amount of this is injected under the skin of an animal or man suffering from the same disorder in its incipient stages, the antitoxin prevents the development of the disease. The use of this method has thus far been much more medical than surgical, and its results in diphtheria and other medical disorders have been perfectly marvellous. In surgery, however, less favorable results have been obtained, but in all probability in the future we shall be able to do for some of our surgical disorders what the physician can do to-day for diphtheria. [For the results in diphtheria, see Professor Osler’s paper.]
There has also been discovered another means which in surgery has rendered some valuable service. From certain organs, as, for instance, the thyroid gland (the gland whose enlargement produces goitre), we can obtain a very potent extract of great value. In cases of goitre very noteworthy results have already been obtained by the administration of the thyroid extract. A number of other organs in the body of animals have been used to combat certain disorders in the human body with advantage. The chief development of both of these new forms of medication, however, will take place in the twentieth century.
INSTRUMENTS OF PRECISION
Another direction in which the century has seen enormous progress is in the introduction of instruments of precision. When I was a student in the early 60’s, instruction in microscopy was conspicuous only by its absence from our medical curriculum. Now every student who graduates is more or less of an accomplished microscopist, and carries into his practice the methods and observations which the microscope furnishes. At the same period I remember being greatly interested in a discussion which two of my teachers had as to whether it was possible to make an application accurately to the vocal chords in the larynx. Now every tyro in medicine makes such applications to the larynx as a routine procedure in cases requiring it, and similar methods have been applied by the ophthalmoscope to examine the interior of the eye; the rhinoscope, to examine the interior of the nose; the otoscope, for examination of the ear; and other similar instruments for examining all the other hollow organs in the body. If I add to these the hypodermatic syringe; the aspirator, which may be described as a large hypodermatic syringe for suction instead of injection; the clinical thermometer, which was introduced in the late 60’s; the hemostatic forceps, for controlling hemorrhage by seizing the blood-vessels and clamping them till we have time to tie them; and other instruments intended to facilitate our operative methods, it will be seen at once that the armamentarium of the modern surgeon is very different from that of his predecessor at the beginning, or even at the middle, of the century.
THE RÖNTGEN RAY
One of those extraordinary discoveries which startle the whole world came nearly at the end of the nineteenth century, in the winter of 1895–96. At that time a modest professor in the University of Würzburg announced that he could readily see the skeleton inside the body through the flesh! Naturally, the first announcement was received with almost absolute incredulity; but very soon his discovery was confirmed from all sides, and it has now taken its place among the recognized phenomena of science. By means of certain rays, which, being of unknown nature, were called “X”-rays, after the well-known mathematical X, or unknown quantity, Professor Röntgen has shown us that not only can the bones be seen, but that almost every substance in the body can be seen and reproduced in pictures. The reason for this is because they are all obstacles to the passage of these X-rays and so produce shadows on a sensitized photographic plate. If the exposure is sufficiently prolonged the rays penetrate even through the bones and act upon the photographic plate, so that no shadow remains. If the rays are allowed to penetrate for a shorter time the bones show dense shadows, and one can get a light shadow of the soft parts. If the exposure is still shorter, then we can recognize the dense shadow of the bone, the much less dense shadows of the muscles, and the still lighter shadows of the layer of fat immediately under the skin. The heart can be seen beating, and its shadow is now a well-recognized feature in skiagraphs of the chest. At first it was thought impossible to discover anything inside the bony skull, but there are now on record nearly a score of instances in which bullets have been detected within the skull, and after trephining have been found and removed exactly at the location indicated. It is a very common thing now to locate a piece of steel or other similar foreign bodies within the eyeball by the method of Dr. Sweet, or some similar method, within one or two millimetres (a millimetre is one-twenty-fifth of an inch). It is now well recognized that even stones in the kidney will throw shadows sufficiently strong for them to be recognized, and by noting their level in relation to the vertebræ we can tell precisely in what part of the kidney to make the incision in order to find and remove them. It has happened to myself and many other surgeons in the past to cut down upon a kidney, believing that there was a stone in the kidney, only to find that we had been misled by the apparently clear symptoms of such a foreign body. In future no such mistake should be made by any surgeon within reach of a skilful skiagrapher. Unfortunately, gall stones and numerous other foreign bodies, vegetable substances such as beans, corn, wood, etc., being as transparent to the X-rays as are the soft parts, are not revealed by means of this new method of investigation; but cavities in the lung, abscesses in bone, and similar diseases which produce thinning of the lung, bone, and other such organs, and so lighten instead of deepen the shadows, can now be recognized by means of light spots in the pictures as well as others by means of a shadow.
I spoke a moment ago of the need of a “skilful” skiagrapher, for it must be remembered that there may be the same difference in the personal skill, and, therefore, in the reliability of the results in skiagraphy as there is in photography. A poor photographer will get very different results from a skilful one, even if he uses precisely the same quality of plates and precisely the same camera. Personal skill and experience in the skiagrapher is, therefore, one of the most important elements in success. It must be remembered also that the X-rays in not a few cases may mislead us. I have, personally, fractured a bone on account of deformity, taken an X-ray picture immediately after the operation, the picture showing not the slightest evidence of a fracture, which I absolutely knew existed. Moreover, foreign bodies found on the outside of the person may mislead us, as, for example, the metal part of suspenders, a coin in one’s pocket, and such like. They look in the picture as if they were inside rather than outside the body, and any article the shape or size of which would not reveal its nature might easily be mistaken for a foreign body within the patient. Therefore, in many cases only an expert can determine precisely what the skiagraph means. I especially mention this, because there is a tendency at present to utilize skiagraphs in court in order to convince the jury that such a picture is an evidence of malpractice. Such pictures always need an interpreter in order to judge correctly of their meaning. It is precisely as if the jury were asked to look through a microscope. I have been myself accustomed to use the microscope for thirty years, but there are many instances even yet in which I am obliged to ask a pathologist or bacteriologist what I really am looking at in the microscope. While one may make a mistake of small moment in some cases, yet if a man’s life or liberty or purse is at the mercy of a jury which does not know how to interpret a skiagraph, and, may, therefore, give a verdict which is “precisely wrong,” as Professor Lincoln, my old teacher of Latin, used to call many of our translations, it will be a very serious matter and lead to gross injustice.
CITY AND VILLAGE HOSPITALS
Another great improvement in our means of caring for our surgical patients is the establishment of hospitals all over the land. These, happily, are not limited to our great cities, but in every country town and not a few large villages small but well-equipped and well-managed hospitals have been established which have done incalculable good. It is not too much to say that every city or town establishing such a hospital is repaid a hundredfold.
TRAINED NURSES
The trained nurse has fortunately come to stay. In fact, our antiseptic methods as above described have made the trained nurse indispensable. The old nurse, who, by many clumsy experiments on her patients, had obtained a certain rule-of-thumb knowledge of the care of the sick, can no longer assist in a surgical operation or properly care for any surgical patient. The modern nurse must of necessity be a well-educated, well-trained woman, knowing thoroughly modern antiseptic methods, and on the alert to observe every symptom of improvement and every signal of danger.
Without a well-trained nurse it is impossible at the present day properly to care for any serious surgical case, and I gladly bear witness to the intelligence, fidelity, and skill of scores of nurses who have assisted me, and without whom I should have felt as one blade of a scissors without its fellow.
SPECIAL OPERATIONS
_Amputations and Compound Fractures._—Having now traced the different modes of thought which have aided surgical progress in the nineteenth century and the improved means of investigation, let us turn finally to the progress in individual operations. As to amputations and compound fractures, I have already indicated the immense improvements which have followed the introduction of anæsthesia, and especially of antisepsis, which have brought the mortality of amputations down from fifty or sixty per cent. to ten or fifteen per cent., and in compound fractures, once so dreaded, since the mortality was not infrequently as high as two out of three, to a relatively insignificant danger.
_Tumors._—In no department, perhaps, has the introduction of antisepsis, and the use of catgut and silk ligatures after the antiseptic method, brought about a greater improvement than in operations for tumors. The startling reluctance of Sir Astley Cooper to operate on King George IV. for so simple and small a tumor as a wen, lest erysipelas might follow and even destroy his life, is in marked contrast with the success and therefore the boldness of modern surgeons. Tumors in all parts of the body, whether they be external or internal, whether they involve the wall of the chest or are inside the abdomen, are now removed with almost perfect safety. Anæsthesia has made it possible to dissect out tumors in so dangerous a region as the neck, where the surgeon is confronted with adhesions to the jugular vein, the carotid artery, and the nerves of the neck and of the arm, with the greatest impunity. Such an operation not uncommonly lasts from three-quarters of an hour to an hour and a half, and involves often the removal of two or three inches of the jugular vein and many of the large nerves, the removal of which a few years ago would have been deemed an impossibility.
_Goitre._—One of the most striking instances of progress is operations on goitre. Writing in 1876, the late Professor Samuel D. Gross noted it as something remarkable that Dr. Green, of Portland, Maine, had removed seven goitres with two deaths, and the late Dr. Maury, of Philadelphia, had extirpated two goitres with one death. In marked contrast to this Professor Kocher, of Berne, in 1895, reported one thousand cases, of which eight hundred and seventy were non-cancerous, and he lost of these last but eleven cases, or a little over one per cent. In 1898 he reported six hundred additional cases, with only one death in the five hundred and fifty-six non-cancerous cases, or a mortality of only 0.1 per cent. It will be seen, therefore, that an operation which a few years ago was excessively fatal has become almost, one might say, a perfectly safe operation.
_Surgery of the Bones._—Operations on bones, apart from amputations, show also a similar improvement. In cases of deformity following fracture we now do not hesitate to cut down upon the bone and refracture it or remove the deformed portion, join the ends together, dress the part in plaster of Paris to secure fixation, and have the patient recover with little or no fever and no suppuration. Above the elbow a large nerve runs in a furrow in the arm bone, and in case of fracture this is liable to be torn and a portion of it destroyed. The result of it is paralysis of all the muscles on the back of the forearm from the elbow down and consequent inability to extend either wrist or fingers, making the hand almost useless. In a number of cases the nerve has been sought for and found, but the ends have been too far apart for successful union and sewing them together. In such cases we do not hesitate now, in order to bring the two ends of the nerve together, to remove one or two inches of the arm bone, wire the shortened bone, sew the now approximated ends of the nerve together, put the arm in plaster, and as soon as the wound is healed, with appropriate later treatment to the muscles we can obtain in a reasonable number of cases a perfect, or almost perfect, union of the nerves with a re-establishment of the usefulness of the hand.
In very many cases the bones are deformed as a result of rickets, and in some cases in consequence of hip-joint disease. In such cases the leg is crooked or flexed, and cannot be used for walking. Such cases of stiff joints and crooked legs are now operated on, one might say, wholesale. At the International Medical Congress, held in Copenhagen in 1884, Professor Macewen, of Glasgow, reported 1800 operations on 1267 limbs in 704 patients, in which he had sawn or chiselled through the bones so as to fracture them, placed them in a straight position, and after a few weeks the bone has become consolidated and the leg or arm made straight. Every one of these operations was successful, excepting five cases, and even these deaths were not due to the operation, but to some other disorder, such as an unexpected attack of pneumonia, diphtheria, or scarlet fever.