PART II. PRACTICE OF SURGERY

INTRODUCTORY SECTION

Part 8. Introduction. Recent Developments in Surgery.

A great change has taken place in the practice of surgery since the publication (1860) of the article SURGERY in vol. xx. of the 8th edition of the present work. This change is due in great part to the fact that the germ theory of disease has been accepted by the majority of surgical teachers and practitioners. Scientific men have demon-strated that the causation of many diseased conditions is closely connected with the presence in the diseased organ, tissue, or individual of living organisms, which have to a I certain extent been classified, and are supposed to be forms of plant life. In one sense it is perhaps unfortunate that the article on surgery has to be written at the present time, because, while there are few who now hold that these or-ganisms are inert, there are some who do not grant that they are the cause of disease; and there are many differ-ences of opinion as to the best methods of applying this scientific knowledge to practical use. In other words, although much of the surgical practice of the present day-is founded on a scientific basis, the practical details are still matter of dispute.

Improve- It is impossible in the present sketch to go with any merits iii fulness into the details of the experimental research by treat"1 which the truth of the germ theory was proved; but some me'nt. allusion must be made to the salient points which have a bearing on the work of the surgeon. It has long been known that subcutaneous injuries follow, as a rule, a very different course from open wounds ; and the past history of surgery gives evidence that surgeons not only were aware of this great difference but endeavoured, by the use of various dressings, empirically to rjrevent the evils which were matters of common observation during the healing of open wounds. Various means were also adopted to pre-vent the entrance of air, e.g., in the opening of abscesses by the "valvular method" of Abernethy, and by the sub-cutaneous division of tendons in the common deformity termed " club-foot." Balsams, turpentine, and various forms of spirit were the basis of many varieties of dress-ing. These different dressings were frequently cumber-some, difficult of application, and did not attain the object aimed at, while at the same time they retained the dis-charges, and gave rise to other evils which prevented rapid and painless healing. In the beginning of the 19th cen-tury these complicated dressings began to lose favour, and practical surgeons went to the opposite extreme and applied a simple dressing, the main object of which was to allow a free escape of discharge. Others applied no dressing at all, laying the stump of a limb after amputa-tion on a piece of dry lint, avoiding thereby any unneces-sary movement of the parts. Others left the wound open for some hours after an operation, preventing in this way any accumulation, and brought its edges and surfaces to-gether after all oozing of blood had ceased and after the effusion, the result of injury to the tissues by the instru-ments used in the operation, had to a great extent sub-sided. As a result of these various improvements many wounds healed in a thoroughly satisfactory manner. But in other cases inflammation often occurred, accompanied by pain and suppuration or the formation of pus, and various feverish conditions, due to and in some way connected with the unhealthy state of the wound, were ob-served. These constitutional sequelae frequently proved fatal and the general impression of surgeons was either that the constitution of the patient rendered him liable to these conditions, or that some poison had entered into the wound, and, passing from it into the veins or lymphatic vessels that had been cut across, reached the general circu-lation, contaminating the blood and poisoning the patient. The close clinical association between suppuration (or the formation of pus) in wounds and many of those fatal cases encouraged the belief that the pus cells from the wound entered the circulation (whence the word " pyaemia "). It was also frequently observed that a septic condition of the wound was associated with the constitutional fever, and it was supposed that the septic matter passed into the blood (whence the term " septicaemia"). It was further observed that the crowding together of patients with open wounds increased the liability to these constitutional disasters, and every endeavour was made by surgeons to separate their patients and to improve the ventilation of the larger hospitals. In building hospitals the pavilion and other systems, with windows on both sides and cross ventilation in the wards, were adopted in order to give the patients as much fresh air as was attainable. Hospital buildings were spread over as large an area as possible; the blocks were restricted in height, and if practicable were never higher than two stories. The term "hospitalism" was coined by Sir J. Y. Simpson, who collected statistics com-paring hospital and private practice, by which lie en-deavoured to show that private patients were not so liable to those constitutional sequelae.

This wras very much the condition of affairs when Lister Lister's in 1860, from a study of the experimental researches of &^rm Pasteur into the causes of putrefaction, stated that the alu| ^' evils observed in open wounds were due to the admission treat-into them of organisms which exist in the air, in water, on ment of instruments, on sponges, and on the hands of the surgeon, wounds. These organisms, finding a suitable nidus for their growth and development in the discharges and surrounding tissues, germinate in them and alter their chemical constitution, forming various poisonous compounds, which, if absorbed into the blood, give rise to pyaemia and septicaemia. Having accepted the germ theory of putrefaction, he ap-plied himself to discover the best way of preventing these organisms from reaching the wound from the moment that it was made until it was healed. He had to deal with a plant and he desired to interfere with its growth. This was possible in one of two ways,—either (1) by directly destroying or paralysing the plant itself before it entered the wound or after it had entered, or (2) by an interference with the soil in which it grew, for example, by facilitating the removal of the discharges and preventing their accumu-lation in the wound cavity, and by doing everything to prevent depression of the wounded tissues, because healthy tissues are the best of all germicides. Several substances were then known possessing properties antagonistic to sepsis or putrefaction, and hence called "antiseptic." Act-ing on a suggestion of Lemaire's, Lister chose for his experiments carbolic acid, which he used at first in a crude and impure form. He had many practical difficulties to contend with,—the impurity of the substance, its irritating properties, the difficulty of finding the exact strength in which to use it: on the one hand, he feared to use it too strong, lest it should irritate the tissues to which it was applied and thus prevent healing; on the other hand, he feared to use it too woak, lest its true antiseptic qualities should be insufficient for the main object in view. It is unnecessary to dwell on the details of his tentative ex-periments. As dressings for wounds lie used various chemical substances, which, being mixed with carbolic acid in certain proportions, were intended to give off a quantity of carbolic acid in the form of vapour, so that the wound might be constantly surrounded by an antiseptic vapour which would destroy any organisms approaching it and at the same time not interfere with its healing. At first, although he prevented pyaemia in a marked degree, he, to a certain extent, irritated his wounds and prevented rapid healing. He began his experiments in Glasgow and con-tinued them after his removal to the chair of clinical surgery in Edinburgh. After many disappointments, he gradually perfected his method of performing operations and dressing wounds, which will be best understood by an illustration.

A patient is suffering, let us say, from a diseased con- Ampu-dition of the foot necessitating amputation at the ankle tataon at joint. The part to be operated on is enveloped in a towel joint which has been soaked with a 5 per cent, solution of car-bolic acid. The towel is applied two hours before the operation, with the object of destroying the (putrefactive) organisms present in the skin. The patient is placed on the operating table, and brought under the influence of chloroform ; the limb is elevated to empty it of blood, and a tourniquet is applied round the limb below the knee. The instruments to be used during the operation have been previously purified by lying for half an hour in a flat porce-lain dish containing carbolic acid (1 to 20). The sponges are lying in a similar carbolic lotion. Towels soaked in the same solution are laid over the table and blankets near the part operated upon. The hands of the operator, as well as those of his assistants, are thoroughly purified by washing them in the same lotion, free use being made of a nail brush for this purpose. The operation is performed under a cloud of carbolized watery vapour (1 in 30) from a steam-spray producer. The visible bleeding points are first ligatured; the tourniquet is removed; and then any vessels that have escaped notice are ligatured. The wound is stitched, a drainage-tube made of red rubber being intro-duced at one corner to prevent accumulation of discharge; a strip of protective (oiled silk coated with carbolized dextrin) is washed in carbolic lotion and applied over the wound. A double ply of carbolic gauze is soaked in the lotion and placed over the protective, overlapping it freely. A dressing consisting of eight layers of dry gauze is placed over all, covering the stump and passing up the leg for about 6 inches. Over that a piece of thin Mackintosh cloth is placed, and the whole arrangement is fixed with a gauze bandage. The Mackintosh cloth prevents the car-bolic acid from escaping and at the same time causes the discharge from the wound to spread through the gauze. The wound itself is protected by the protective from the vapour given off by the carbolic gauze, whilst the sur-rounding parts, being constantly exposed to its activity, are protected from the intrusion of septic contamination ; and these conditions are maintained until sound healing has taken place. Whenever the discharge reaches the edge of the Mackintosh the case requires to be dressed, and a new supply of gauze applied round the stump. The gauze that is used should be freshly made and kept in a tin box to prevent evaporation of the volatile carbolic acid. This precaution is most needful in warm weather. When-ever the wound is exposed the stump is enveloped in a vapour (1 in 30) of carbolic acid by means of the steam-spray producer. At first a syringe was used to keep the surface constantly wet with lotion, then a hand-spray, such as Eichardson's ether-spray producer. More recently a steam-spray producer has been introduced into practice. These dressings are repeated at intervals until the wound is healed, the drainage-tube being gradually shortened and ultimately removed altogether.

In the case of an accidental wound to which the surgeon is called a short time after its occurrence, carbolic lotion (1 to 20) must be injected into the cavity of the wound to destroy any organisms which may have fallen into it. The dressings already described are then applied. In operating on a case in which putrefaction has occurred, every endeavour must be made to destroy the causes of putrefaction which are already present. The substance most frequently used for this purpose is chloride of zinc solution, 40 grains to 1 oz. of water. This powerful anti-septic was extensively used some years ago by Mr De Morgan, Middlesex Hospital, London. When the wound has been thus purified from its septic condition, the after-treatment must follow strictly the plan already recom-mended for a recent wound to avoid secondary contamina-tion at subsequent dressings.

The object Lister had in view from the beginning of his Progress experiments was to place the open wound in a condition since as regards the entrance of organisms as closely analogous Llster-as possible to a truly subcutaneous wound, such as a con-tusion or a simple fracture, in which the unbroken skin acts as a protection to the wounded tissues beneath. The introduction of this practice by Lister effected a complete change in operative surgery. Although the principle on which he founded it was at first denied by many, it is now-very generally acknowledged to be correct. In Germany more especially his views were speedily accepted. In France and England their adoption was slower. In Scot-land, perhaps in consequence of the fact that many saw him at work and worked under him, acquiring perhaps some little part of his persevering enthusiasm, he soon had many believers. Since about 1875 surgeons have been trying to improve and simplify the method; chemists have been at pains to supply carbolic acid in a pure form and to discover new antiseptics, the great object being to get a non-irritating substance which shall at the same time be a powerful germicide. Iodoform, eucalyptus, salicylic acid, boracic acid, corrosive sublimate, have been and are being used, and the question as to their relative superiority is not yet settled. Carbolic acid has the disadvantage of irri-tating the tissues. This is partly counterbalanced by its anaesthetic properties. Absorption of the carbolic acid has occasionally taken place, giving rise to symptoms of poison-ing. But this danger has been greatly lessened by the introduction of pure acid. Of the antiseptics named carbolic acid, eucalyptus, and iodoform are volatile; the rest are non-volatile. At first Lister for some years irrigated a wound with carbolic lotion during the operation, and at the dressings when it was exposed. The introduction of the spray displaced the irrigation method. At the present time the irrigation method is again gaining favour. All these different procedures, however, as regards both the antiseptic used and the best method of its application in oily and watery solutions and in dressings, are entirely subsidiary to the great principle involved—namely, that putrefaction in a wound is an evil which can be prevented, and that, if it is prevented, local irritation, in so far as it is due to putrefaction, is obviated and septicaemia and pyaemia do not occur. Alongside of this great improve-ment the immense advantage of free drainage is now uni-versally acknowledged. Surgeons now understand the dangers which lie on every side, and this knowledge causes them to take greater care in the purification and in securing the greater cleanliness of wounds, and some hold that much of the good result follows from these precautions apart from the principle of the system.

Putrefaction has been clearly shown by Pasteur, Tyndall, Putre-and others to be due to the activity of certain lowly forms factive of organized matter. Scientific men have therefore had their pr£au" attention more particularly directed to these lower forms of plant life. A careful study has been made of their life history, and several diseased conditions are now known to be due to the deposit and growth of organisms of a specific form in the blood and in the tissues. This is not the place to discuss points still sub judice; but there can be no doubt, e.g., that the Bacillus anthracis is the cause of splenic fever and of its local manifestation, malignant pustule, and that erysipelas is due to the presence of a micrococcus. There are many other diseases spoken of as zymotic or fermentative, upon which observers are now at work, and hardly a month passes without the publication of new observations (compare SCHIZOMYCETES). It can certainly be said that the relation between those organisms and various specific diseases is the question which at pre-sent most occupies the attention both of pathologists and of practitioners of medicine and surgery. It is now known that there are many varieties of organisms (in Crookshank's Bacteriology sixty are described), some of which are hurtful to the human economy, though others are apparently harmless. Those of the former class give rise to an alteration in the tissue in which they grow; and during their growth they alter its composition and cause it to break up into various compounds, some of which, when absorbed into the blood-stream, poison the individual. Some, on the other hand, are either in themselves innocuous or are killed when they enter the blood, which is a fluid tissue and acts as a germicide; hence the tissues in a healthy condition are spoken of as "germicidal." Some appa-rently grow only on dead tissue, or in tissue the vitality of which has been lowered.

Ferment- The alteration in the tissue is strictly analogous to a .ations. fermentation—such, for example, as the change which takes place in a solution of grape sugar in which the yeast plant las been planted. The solution breaks up into alcohol and carbonic acid; along with this change there is an increase in the quantity of the yeast. The most common fermenta-tion is the alteration termed "putrefactive" or "septic." The cause of this change is in all probability a special organism named Bacterium termo. It lives on any dead matter containing nitrogen when exposed to heat and moisture; dryness and cold are antagonistic to its growth. Its results are so evident and of such common observation that the term "antiseptic" was used long before the primary cause of the condition was understood. Antiseptics origin-ally were substances which interfered with sepsis. The term has now, however, a wider meaning, and includes any substance opposed to fermentation. " Antifermentative " or " antitheric " would be a better term. An antitheric substance is one which interferes with fermentation by destroying or paralysing the organism which is the primary cause of the condition. The word " antiseptic," on the other hand, should be reserved to denote any substance which is opposed to putrefaction or sepsis,—one form of fermentation. Many of the most dangerous fermentations have nothing in common with putrefaction : the products which result are odourless; the appearances which arise bear no similarity to the changes which occur when putre-factive fermentation is present. Plant the Bacterium lactis in milk, and souring, or the lactic acid fermentation, takes place; plant the Bacterium termo in milk, and putrefactive fermentation occurs. The fermentations of smallpox, vaccinia, syphilis, scarlet fever, typhoid, relapsing fever, typhus, erysipelas, and cholera may be taken as examples of fermentations of the non-putrefactive class. Apparently in them the organism enters the blood-stream, there de-velops and forms its products, which, acting directly or in-directly on the heat-centre, give rise to a specific fever. This fever continues until the soil is worn out, and the organism, finding no longer a nidus for its development, dies out, and recovery takes place. Death of course results if the individual has not sufficient strength to withstand the attack. There is a general law regarding all living things which holds true of these lowly organisms as of the highest: remove its food and the organism dies, or at any rate ceases to develop. It may, however, lie quiescent, again appearing when a new nidus is provided for it. These considerations explain the reason why, after one attack, the individual is protected for a longer or shorter period. They also explain why many diseases are becoming through course of time less virulent than they once were: the soil is becoming exhausted in relation to the special require-ments of the organism, and the organism is therefore incapable of flourishing as it formerly did. Plant the organism in a virgin soil—take, for example, as was un-wittingly done, the organism of measles to Fiji—and a disease which in Great Britain is comparatively harmless becomes a most deadly scourge.

An attempt has been made to divide organisms into two Infective great divisions—the infective and the non-infective. The first class can grow in living tissue; the second cannot. The first form their products in living matter; the second can only grow in dead or lowly vitalized- matter. The infective organism can migrate from the original point of en-trance by the vascular and lymphatic streams to distant parts of the body, and may there form secondary foci of infection. As regards the non-infective the manufactory of the poison is principally restricted to the near neighbour-hood of the original point of entrance, generally a wound. It cannot migrate into the living tissues around if they remain healthy. Both kinds of organism form ptomaines (TTTCO/XO, a carcase), the products of the fermentation which result from the breaking up of the tissue or discharge in which the organisms grow. They may enter the blood-stream and poison the patient. Their entry into the blood must be differentiated from the entry of the organism itself into the stream. Clinically, the two conditions, although often met with in one individual, are in many cases distinctly separable. This physiological division of organisms into infective and non-infective is at present only tentative, and much work must be done before a strictly physiologi-cal classification can be attempted; at present the main line of inquiry must be principally morphological. Even in this direction a difficulty meets the observer, because organisms change their shape according to the media in which they are cultivated.

In the present article only a general view of the present aspects of surgical practice can be given. Special stress will be laid upon the principles which guide the surgeon in his daily work. For full particulars with reference to any special points the reader is referred to Holmes's System of Surgery, Erichsen's Science and Art of Surgery, and Gross's System of Surgery.

Surgical affections may be divided into two great classes, —those which are the result (1) of injury and (2) of disease.


Footnotes

679-1 The gauze dressing consists of thin gauze which has been soaked in a mixture of carbolic acid (1 part), resin (5 parts), and paraffin (7 parts). The object of the paraffin is to prevent the gauze sticking to the skin. The resin retains the carbolic acid and prevents evaporation at the ordinary temperature; at the temperature of the body, however, a certain quantity of the carbolic acid is constantly being given off, and in this way the part operated on is enveloped in a vapour of carbolic acid. This antiseptic vapour persists as long as there is any carbolic acid in the gauze. A gauze dressing is not reliable for more than a week ; by that time the carbolic acid in the gauze is dissipated aud the dressing requires to be renewed.

680-1 John Hunter defines '' vitality " as the power which resists putre-faction.





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