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.