Notwithstanding the great step made by the introduction of ether and chloroform, the medical man is to-day still dissatisfied and is continually endeavoring to discover some agent or combination of agents which will produce insensibility to pain without unconsciousness and without the slight danger and the uncomfortable after effects of chloroform and ether. An ideal anæsthetic then must be a local anæsthetic, one that will render the field of operation insensible and be without the slightest danger to the patient.
Local Anæsthesia.—At the beginning of our century freezing with ice alone, or with ice and salt, was the only method employed for producing local insensibility. Freezing as a local anæsthetic was, however, not extensively used until fifty years later, when Dr. Richardson of London showed the anæsthetic effect of spraying the surface of the tissues with ether. During the late sixties this method of freezing became quite popular for producing local anæsthesia for small operations such as extraction of teeth, removing nails, opening abscesses, etc., and occasionally was employed for more protracted operations, Cæsarian section having been performed a number of times by the aid of this agent. The rhigolene spray was found later to be more satisfactory than ether in many respects, and the two together were frequently used.
Another freezing agent which is now used very extensively and has entirely supplanted those just mentioned is the chloride of ethyl. This, when applied to the dry skin, produces in a few seconds complete freezing, and renders the surface comparatively painless for many of the minor surgical operations.
The properties of cocaine as a local anæsthetic were known thirty years ago, but it was not until 1884 that Dr. Kohler of Germany demonstrated its practical applicability. To-day most of the operations on the eye, nose, and throat are performed under the pain prevention afforded by this drug, and in general surgery it has an extensive field, being found satisfactory where freezing is inapplicable or general anæsthesia not desired, as, for instance, in removing small tumors, splinters, ingrowing nails, etc. In the eye, nose, and throat it is applied simply in solution to the mucous membrane, but where anæsthesia of the skin is desired, it is necessary to inject it under the skin with a hypodermic syringe. When used in strong solutions this remedy is dangerous, and it has lately been shown that weaker solutions when used in larger quantities are just as satisfactory and less dangerous.
A recent substitute for cocaine is eucaine; but, although less dangerous, it is less satisfactory and not harmless to the tissues themselves.
Antiseptic and Aseptic Surgery.—Excepting the introduction of anæsthesia, no greater step has ever been made in surgery than that which was brought into use by the antiseptic and aseptic method of treating wounds. It is now about thirty years since Sir Joseph Lister, believing in the so-called “germ theory,” evolved by Pasteur, Virchow, and others, advocated the use of agents which were destructive to germ life in the treatment of wounds. At first the great antiseptic, and the one used most generally by Lister, was carbolic acid, which was applied to the wound in solution, and used as a spray during the performance of operations, to protect the wound from infection by germs in the atmosphere. It was not long, however, before it was discovered that the danger lay not in the atmosphere but in the skin of the patient and in the hands of the surgeon and in the condition of his instruments and dressings; and to these sources attention was given with results known to us all. Other antiseptics, such as bichloride of mercury and boric acid, afterward came into use, and within the past ten years the first of these two has largely supplanted carbolic acid, and is the one reliable and practical destroyer of germs. The antiseptic treatment of wounds was probably not in full swing until about 1885–1890, and was quickly followed by the more recent aseptic method. These two can, however, never be successfully separate, as the latter is dependent entirely upon the former; that is, in order to render the field of operation and the hands of the surgeon aseptic, the antiseptics must be used. Asepsis means without poisonous germs, and, as applied to surgical treatment, it is essential that, after the instruments, the dressings, the patient’s skin, the surgeon’s and his assistants’ hands have been thoroughly cleaned with soap and water and rendered free from germs, there be use of antiseptic solutions in the wound or on the dressings. This has been a great step forward, this discovery that it was in the skin that the germs lurked, and that soap and water and a scrubbing brush were as necessary as antiseptics. Few surgeons to-day employ antiseptic solutions in wounds unless the wound itself is already infected, when it becomes necessary. In wounds which are clean and made by the surgeon under aseptic conditions, no antiseptic drug is required which may indeed be actually harmful, for these chemicals which destroy germs are not altogether harmless to healthy tissue, particularly when used in strong solution.
The discovery of anæsthesia and the promulgation of the germ theory of inflammation, together with the subsequent perfection of the means of destroying microbes, all within the memory of many now living, have revolutionized surgery to such an extent that the surgeon reaches fearlessly into regions which before were impracticable, and undertakes operations which were never even dreamed of a generation ago. One can readily imagine that no surgeon would care to undertake, and no patient would endure, the agony of an operation lasting for several hours without an anæsthetic; and that it must have been only an immediate and certain danger of death that compelled a surgeon, in pre-antiseptic days, to open an abdomen or brain when he realized the great probability of subsequent inflammation and death.
Let us look at some of the individual advances of surgery since the introduction of anæsthesia and of the use of germ-destroying agents, considering first, simple fractures.
Of Simple Fractures.—Anæsthesia was the means of permitting surgeons to “set” fractures in a satisfactory manner and without pain; and the use of antiseptics has prevented many of these fractures from becoming compound fractures. Lately there has been a change in the general treatment of fractures which is proving a great advancement. Formerly it was the custom to keep not only the broken bone itself perfectly quiet on a splint until union had taken place, but also to immobilize all the neighboring structures, joints, muscles, and tendons. This meant that when the limb was taken off the splint, not only would the bone be “solid,” but there was also a tendency to fixation of the muscles and joints, so that it took the patient as long to get back the use of the limb as it did to unite the broken bone. This is now obviated in many fractures by beginning both the passive and active motion of the neighboring muscles and joints at a much earlier period than heretofore; in fact, in many fractures, such as those near the wrist, by never allowing these adjacent structures to get stiff at all, but keeping up the passive motion (while the fragments are held firmly together) from the very first dressing. In other more complicated and serious fractures where motion is contra-indicated, the use of carefully applied massage prevents largely the stiffness and the wasting of the muscles which results from long confinement on splints.
Compound Fractures.—In pre-antiseptic days compound fractures were one of the greatest causes of the amputation of limbs; and yet, to-day, these same breaks, which twenty-five years ago would have cost the patient his limb, are, by means of antiseptics, rendered aseptic and converted into a simple fracture by the closing of the wound, and the part is not only saved but fully restored to function.