How we treat wounds to-day; a treatise on the subject of antiseptic surgery which can be understood by beginners

Front matter

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AS7 librarTof congress.

A TREATISE ON THE SUBJECT OF ANTISEPTIC

Contents

PAGE

First Word ........ iii

General Remarks

Chapter I

Let us build upon the following syllogism which is not of sand.

All surgeons who understand antiseptic wound treatment work antiseptically.

Not all surgeons work antiseptically.

Therefore, not all surgeons understand antiseptic wound treatment.

The premises may be challenged by men who do not work antiseptically, but at the bottom of the trouble is rather the method of the individual than any fault in the antiseptic method.

Some men who stand high in the profession have expressed themselves as opposed to the new and scientific way of treating wounds, but this is in fact because they have not had ex-

2 HOW WE TREAT V/OUNDS TO-DAY,

perience with clinical demonstrations of genuine antisepsis and its results.

Students sometimes excuse themselves from an acquaintance with modern methods because a certain professor in surgery, for whom they have great respect, has not made himself,, familiar with the subject.

Because Cato learned Greek at the age of eighty years very few of us are inclined to think that the Greek language was previously unknown ; and the professor and his students will find that time will break down their opposition, or, in other words, will supply their lack of information.

Lack of information in this connection means that opportunity for learning has not been given ; and this opportunity has not been widely given in America, because teachers have been too few, and because the text-books on the subject of antiseptic surgery have been too elaborate for beginners.

In a few years this country will do as good or better surgical work than Germany is now doing, but in the meantime patients and physicians will experience much suffering and disappointment where comfort and satisfaction might be had.

The history of antiseptic surgery is not different from the history of previous radical advances in civiHzation.

At present the brightest hghts in the profession form the head of the comet, while stringing out into the tail are multitudes who can never change their positions.

In order to fully comprehend our modern wound treatment, one must have a knowledge of the life-histories of micro-organisms ; although a simple appreciation of the fact that microbes are continually on the alert for free board and lodging would be sufficient to put most men on guard against them.

If you shake a puff-ball the air in the vicinity is filled with spores, Avhich become new puftballs so soon as circumstances favor.

If a septicaemia patient should be shaken, the air would in the same way be filled with spores, which would proceed to make new septicaemia microbes at the very first opportunity.

The micro-oro-anisms, in different stai^'es of development, which are constantly floating about us are successful monopolists ; and they betake themselves with their families to any spot where a bit of fertile territory is opened up — appropriating all food products within reach.

Expose fresh apple juice to the air and micro-organisms will fall into it.

The species which are fond of the sugar increase most rapidly, and demanding part of the elements of the sugar molecule, allow the remaining atoms to arrange themselves into alcohol and so-called carbonic-acid gas. — Cider results.

Other species which grow more slowly proceed to attack the alcohol, and leave acetic acid in its place. — Vinegar results.

When a large wound is exposed to the air many microbes are made happy, and the species which feed upon the albuminous discharges begin work at once ; destroying the plastic lymph which is thrown out, and leaving sulphur-alcohols and ethers in their trail.

The wound has taken on new life, but not the kind of new life which we wanted ; and now WE TREAT WOUNDS TO-DAY. 5

irritation, caused by the microbe growth, forces nature to resort to a subterfuge in order to heal.

How the old pathologists did love to see an abundance of ''laudable pus "! believing that its presence with granulating surfaces was a thing to be desired.

Ordinarily, suppuration and undue local inflammation are the worst results of the growth of micro-organisms ; but if any septicaemia or pyaemia, or erysipelas spores happen to be about, they claim a share of the spoils, and not content with what is set before them, break into and mob the general commissary department of the patient.

We have, however, the power to prevent the growth of such micro-organisms in wounds.

When the surgeons of earlier davs used balsams and essential oils in their dressings, an approximation to the condition of antiseptics was brought about.

When carbolic acid came into vogue, an improvement in wound treatment followed, because carbolic acid was a better antiseptic substance than oil or balsam.

Bichloride of mercury has proved to be a better germicide than carbolic acid.

Not until Sir Joseph Lister poured together into his large crucible, extracts from greengrowing theories and from cut and dried facts, did the pure crystals of antiseptic science appear.

Lister it was who first taught us to apply systematically and accurately a method which would ensure for our wounds protection against the hordes of intriguing microbes, and although his particular method has been simplified and superseded in other countries, the underlying principles remain the same, and subtend all the modifications of the improvers.

To the prime mover in London is due the credit of giving to the world a better means for preventing suffering than has ever before been given by any one man. There are men, of course, who will object to this claim ; but you cannot argue constitutional law with a hod-carrier. Neither can you avoid hearing the fire-crackers which pop while the boom o£ the cannon is reverberating.

HOW WE TREAT WOUNDS TO-DAY. J

It is now possible to gain primary union in almost all wounds ; and operators who work antiseptically believe as causators that primary union goes not by luck but by law ; and further, that they are able to inhibit breakers of the law.

Mr. Lister believed his wounds to be aseptic, and the belief has caused greater dispute than its importance warrants ; for whether or not microbes are present in a wound, is a matter of no importance, provided that their growth be so hindered that natural reparative processes are not interfered with.

It seems to me that the word antiseptic is a better word than aseptic as a qualifyinoadjective.

At the present day we control microbe growth with substances which in themselves cause so little disturbance to the wound that danger from them is seldom to be feared. For instance, among hundreds of wounds which I have seen in this and in other countries, which were treated with bichloride of mercury, only one serious case of poisoning has been produced

8 HOJV WE TREAT WOUNDS TO-DAY.

That case was furnished by a patient of my own, and the accident will not occur again, although I shall continue to use bichloride of mercury until a better material can be substituted for it.

The patient in question will be referred to again in another chapter.

A localized eruption of the skin, caused by the carbolic acid or bichloride of mercury used in dressings, will appear in perhaps five per cent, of our cases, but it amounts to nothing, and is preferable to untimely eruption of the spirit.

Think of the numbers of patients in whose wounds antiseptics make no unwished for demonstration.

Every thing in this world is comparative.

Think of the numbers who formerly suffered and died from septic infection, or from the effects of prolonged suppuration, because antiseptic treatment was omitted.

Surely sins of omission may be greater than sins of commission in surgery.

Do we deprive patients of an anaesthetic because deaths have occurred during anaesthesia ?

Most assuredly not.

If deaths from such a cause are placed in the balance with deaths from shock where an anaesthetic was not employed, which side do we find the heavier ?

If we put deaths from corrosive-sublimate poisoning on one side of the balance, and deaths from wound infection on the other side, the latter go down with such a thump that the former are hurled high in air and scattered to the winds.

A mild statement is made when we say that more misery can be avoided by actual scientific antisepsis surgery than by anaesthesia.

Many shadows are thrown on actual scientific antiseptic by men who suppose that they are doing orthodox work when they are really doing nothing of the sort. These operators hurt the reputation of the cause.

If an operation should be performed when an anaesthetic had carried the patient to the stage of excitement only, would an observer believe that anaesthesia was greatly beneficial ?

If a surgeon employ corrosive sublimate or carbolic acid in dressing a recent com[Hnind lO HOW WE TREAT WOUNDS TO-DAY.

dislocation of the carpus, and is obliged to change the dressings a few days later on account of suppuration, does the spectator carryaway a favorable idea of antiseptic treatment?

In either case the fault would lie in the method of the individual, but in each case one who did not know better would take the principle to task.

During the first six months of my service on the house staff of Bellevue Hospital, in the winter of 1882-3, I saw several deaths from pyaemia, septicaemia, and erysipelas.

We believed that our division was doing a great deal of antiseptic work, and although our records were much better than previous ones had been, patients dreaded the very name of the hospital.

In spite of the energetic care of Warden O'Rourke, and in spite of the general cleanliness insisted on by many of the visiting surgeons, the dread diseases were almost continually present in the wards, and we dared operate upon the most urgent cases only.

If varicocele were operated upon at that time by the method of* opening the scrotum

HOW WE TREAT WOUNDS TO-DAY. II

Widely, ligating the vessels above and below, and snipping out the mass of veins with scissors, the patient would have been almost certain to develop phlebitis.

A year later, and the surgeon who lost such a case from phlebitis would lose caste in the profession, and he would perhaps go back to the clumsy old method of ligating the veins subcutaneously.

Subcutaneous surgery and surgery in the dark are synonymous.

In April, 1883, when Dr. Frederick Lange introduced scientific antisepsis into the wards of the Second Surgical Division of Bellevue Hospital, a very active revolution in wound treatment followed.

Dr. Sands at Roosevelt Hospital, Dr. Weir at New York Hospital, and Dr. Bull at Chambers Street Hospital, in New York, were already acknowledged American leaders in the new surgery.

In July, 1883, Dr. Lange went on dut)- as Visitinor Surgeon to the Fourth Suro-ical Division of Bellevue Hospital, and in not o\\^ case from that time until the end of \\\\ service.

in April, 1884, did septicaemia, pyaemia, or erysipelas follow operations or attack accidental wounds.

The profuse suppuration to which we had become accustomed disappeared as if by magic, and instead of spending several hours daily in changing dressings, we employed only a few minutes in that sort of work, the number of operative cases being at the same time very greatly increased.

Patients became enthusiastic and brought friends for us to operate upon, and the house staff exerted themselves to get series of operative cases into the hospital.

We operated aggressively upon every thing which could be operated upon, and we opened the great joints and the peritoneal cavity in the unclean wards.

We employed the permanent dressing in treating our compound fractures.

We wired simple fractures of the patella, washing out the joints, and the wounds healed by primary union.

The wards lost the old-time hospital odor. From a reign of terror we came to a sort of millennium as regards microbe invasion, and the micro-organism and the wound lay down in peace together with a good antiseptic dressing between them.

Some one will say that this old and infected hospital was very different from a private house, and that in the latter place our rigid enforcement of precautionary measures would not have been required.

Let me ask a question or two right here.

Will you, if you live in the purest and freshest of country air, dare to open the knee-joint of a friend and suture a loose semilunar cartilage in place ?

Can you put a dressing on a badly lacerated compound and complicated Potts' fracture and allow that dressing to remain untouched for a month ?

Will you treat housemaid's knee or a large cold abscess by the simple method of opening them freely and trimming out the abnormal lining membrane of the cavities ?

No ! You shiver at the mention if you have not yet learned how to work antiseptically ; and yet we will treat the cases in this wa\\ without hesitation, in our infected hospitals.

A celebrated English laparotomist has been loud in his objections to antiseptic wound treatment, and he champions the cause of extraordinary cleanliness, without antiseptics.

In his private hospital and with trained assistants he gives us most excellent statistics, but if he knew how to use antiseptics properly he would give us far better ones yet. His abdominal wounds would look much prettier, and would heal more rapidly, and with fewer complications, if he would only learn how to treat them antiseptically.

If any one class of operations can be done successfully under extraordinary cleanliness alone — the laparotomies form that class.

Why it is, we cannot at present say. But this much we know, that in general surgery* results are very mournful when antiseptic treatment is not employed.

The fact remains that laparotomies can be done successfully without the employment of microbe-destroying agents ; but given this fact, and how many men are working successfully in abdominal operations without depending upon antiseptics ?

Two or three !

Give these two or three men a knee-joint in which the condyles of the femur have been shot through and through by a number fortyfour Winchester bullet ; and what success would they attain in the way of putting the patient out of danger from inflammation and suppuration ?

In agreat majorityof cases that leg would have to be amputated, and the operators could not avoid exhausting suppuration if it were left on.

We can so manage this wound with antiseptic treatment that the patient will not only retain his limb, but he will have almost no febrile reaction after the operation. iVnd the dressing applied will remain unchanged for several weeks.

Yet these two or three laparotomists have the assurance to tell the general surgeons that antiseptic precautions need not be considered.

It is time that we were done with arguing exceptions instead of principles.

An incalculable amount of mischief is done by these great men, wlio suffer from astygmatism in one or more of their nuMital lucM'idians.

They cannot see the moral horizon of their behefs.

A well-known medical man who has recentlybeen travelling in a foreign country, writes as follows with regard to a certain conversation which he had with a colleague :

'' The statement which most impressed me was that of a professor of clinical surgery of more than thirty years' standing, — a man of enormous experience and attached to one of the largest hospitals I visited, who told me that his deliberate conviction had at length been formed, that the so-called antiseptic system had little to commend it save that of being a very successful system of quackery."

Now I happen to know this ''professor of clinical surgery " to whom the letter refers.

I am very certain that he has never seen an antiseptic operation in his life, but if he has seen one he had no conception whatever of the nature of the work.

His connection with hospital work is at present as slender as the stem of a maidenhair fern.

I have seen, in visits to his ward, numerous cases of septicaemia and pyaemia, and teacupfuls of pus.

To speak charitably of the man I should say — he is too old to learn.

Were he younger it is probable that in time he would come to be a most enthusiastic supporter of antiseptic doctrines.

To-day he jumps away like a frog touched up from behind if the mention of antisepsis be made in his vicinity.

The surgeon who writes says further : ''He put it very much in this way. ' That if from time to time, in every few months, the methods are changed, and with each succeeding change strong statements are made that the last development contains the only security, it must inevitably follow that to the public mind there can be security only in the hands of the inventor himself for the complete and successful accomplishment of details.'"

The above explains the extent of knowledge which the two men possess on the subject of antiseptic surgery.

Who, I should like to ask, is authorIt\- for the idea that ''with each succeeding- chaiv^c

1 8 HOPV WE TREAT WOUNDS TO-DAY.

Strong statements are made that the last de-^ velopment contains the only security " ?

Let me tell both of you, and others who have had no opportunity of familiarizing themselves with the literature of modern surgery, that the supposition expressed above is wholly fallacious and malignant.

Shall we go without watches because different watchmakers are at swords' points as to the details of manufacture ?

No ! All good watches keep time.

Shall we allow patients to suffer because Doctors Popoff and Bonita are not agreed as to the relative merits of iodoform and of carbolic acid in wound treatment ?

No ! Decidedly no !

AH good antiseptic methods save life and prevent suffering.

It is high time, too, that every American surgeon was at work in the knowledge of that fact.

Mr. Lister has recently received the decoration of the order of knighthood pour le merite from the Emperor of Germany.

The honor was bestowed over the heads of Langenbeck, Volkmann, and Billroth, and even over the heads of the two or three laparotomists who urge cleanliness as a substitute for antisepsis.

Is the Emperor of Germany in the habit of honoring foreigners in preference to his own distinguished countrymen ?

It was hardly through oversight that this thing happened, and never was a better earned knighthood than Lister's.

What men are now doing the advance work in surgery ?

Who are the men who are piling up statistics of new and great operations ?

The workers in antiseptic surgery. The men who have no fear of inflammation after operations.

Where would McEwen's and Schede's osteotomies stand to-day were it not for antiseptic surgery ?

Who would conscientiously do \^olkmann's operation for hydrocele, or Miculicz' tarsus exsection, or Petersen's cystotomy, if not assured that septic infection could be prevented ?

Could Bruns have reported, in the Announcement for 1884 of the Tubingen clinic, twenty successive excisions of the knee-joint, with primary union under one dressing in nineteen of them, if he had depended upon any method of cleanhness without antisepsis ?

What do the uninformed think of Esmarch's statement before the Twelfth German Medical Congress, that out of sixty-three successive major operations at his clinic in Halle, fiftyeight healed by primary union under one dressing ?

Scientific antisepsis is, after all, only an exalted degree of cleanliness ; but this exalted degree of cleanliness can be reached through scientific antisepsis alone.

A wound is merely put in such shape that nature can work uninterruptedly.

When we operate on bunions, and charge the patient a couple of hundred dollars for the work which nature does immediately afterward, our consciences are easier than they were in earlier days when we charged the patient four or five dollars for something to put on his bunions, and tried to do the repairing ourselves.

The operation which was really a dangerous one a few years ago has become a very simple one now that inflammation can be prevented.

Objection is often made to the small details in an antiseptic method.

The technique and details go to make up the grand whole, and whoever omits a part of them takes the responsibility upon his own shoulders.

A chain is no stronger than its weakest link. An antiseptic system is no stronger than its weakest detail, which should have been strong.

Many physicians suppose that antiseptic work cannot be readily carried out in private practice, but that hospital facilities must be available.

Let me ask these men if they are going to deprive the literary man, the banker, or the merchant, of the privileges which are accorded the tramp, or the thief who is carried to the hospital ?

As will be shown later it is practically no more difficult to do the work in one place than in another.

I have performed in private practice sucli

Operations as ovariotomy, herniotomy, excision of the knee, etc., at short notice, and with not one essential facihty wanting for the attainment of antiseptic ends.

It is sometimes said that so great pains and so much apparatus are required for doing antiseptic work that the general practitioner cannot carry it out.

This is in a measure true.

The time has come when it is best for the general practitioner to have as little as possible to do with surgery.

In the country, however, where the physician must ride over long distances daily, it is very desirable that the art of applying the permanent dressing be learned.

When this is accomplished the physician will find himself so proud of his results that he will be greatly tempted to give up his general practice.

The test of one's ability to do antiseptic surgery lies in the success which attends the application of the permanent dressing.

Just as many must fail to comprehend Herbert Spencer s definition of '' life/' so must many fail to grasp the intention of antisepsis.

A good old family practitioner of my acquaintance, who recently put up a fracture of the olecranon process in a right-angled position with plaster of Paris, was quite sure that antiseptic methods were not practical.

I know a prosperous merchant who hangs his barometer out of the window so that pressure variations can have easy access to it ; but this does not reflect upon his ability to lead a bull movement in the corn market.

I am acquainted with surgeons who treat amputation wounds by the open method, and who would generally have to amputate in a gun-shot wound of the elbow-joint in order to get a good open wound ; but this does not reflect upon their ability to treat typhoid fever well.

The merchant could easily learn something about atmospheric pressure.

The medical men could with comparatively little trouble learn to save several weeks of healing process after limb amputations, and they would seldom think of amputating in case of compound fracture at the elbow-joint so long as circulation of blood continued in the hand.

As far as the open treatment of wounds is concerned, the method is as far behind the times in surgery as the flint-lock gun is in warfare.

After well-meant attempts at antiseptic work some men will still fail to gain expected results.

This is because they do not do antiseptic work.

The man who jumps over a brook and lands well on the bank is satisfied with the result of his effort.

The man who jumps almost across, but not quit^, is in a very different mood.

There is a considerable difference between jumping entirely over a brook, and jumping almost over it.

The one who falls short will make the most noise.

Let him who can shoot ruffed grouse be the first to describe the bad qualities of red Irish setters.

HOW WE TREAT WOUNDS TO-DAY, 2y

Let him who can apply a plaster of Paris jacket properly be the first to say that Sayre's way of handling spondylitis is not the best way.

Let him who can apply a permanent dressing to a compound fracture at the ankle-joint. be the first to decry antiseptic surgery.