To one educated in surgery a quarter of a century ago, the customs and theories of today must seem very odd, and the results of today's surgical science must seem truly miraculous. Formerly pus formation in a healing wound was regarded not only as unavoidable, but really beneficial. Pus, or matter, was known as laudable or good pus, and diseased, or bad pus. Wounds only occasionally healed by primary union or first intention, that is to say, skin growing to skin and muscle to muscle as sewn, but they rather healed by a long, slow process of granulation attended with pus formation, called second intention. The various surgical epidemics of contagious diseases were extremely common in the very best hospitals under the guidance of the very best men; they were thought unavoidable. Hospital gangrene, erysipelas, and the various forms of blood poison diseases, were so common and spread so rapidly as often to render it necessary to close a hospital. Major operations were attended by a mortality that nowadays seems almost incredible. To amputate a leg, except under the most favorable circumstances, meant almost sure death. The late Dr. Pasteur of France first made known to the world that there were such things as germs, or microscopic life, capable of transmitting themselves and their spores almost endlessly. These germs were soon found to be the outcome of dirt and disease, and that possibly in their extermination lay a great future for surgery. It was Sir Joseph Lister, of England, who first discovered the fact that certain medicines, like carbolic acid, would kill these germs, and that in so doing wounds would unite by first intention in the majority of cases. This was the first great step toward the realization of the dreams of our forefathers.
The study of bacteriology was then commenced, and it has progressed rapidly ever since, till today it has become a marvelous science unfolding the life, nature and propagation of all sorts of bacteria.
We now know that on the living skin there exist normally certain germs whose function apparently is to use up the waste products of the economy, but which, when introduced into the flesh, produce most deleterious effects.
Germlife is found everywhere, on our hands and clothes, in the dust of the air and in the water we drink. So long as they keep to their natural abodes no mischief is done. It is this germlife which causes wounds to suppurate, erysipelas, bloodpoisoning and gangrene to occur. It is the annihilation of these germs about all wounds, and on all objects which come in contact with wounds, that distinguishes the newer from the older surgery. Today the mortality figures are revised as regards all important operations. Regions of the body are invaded which fifteen or twenty years ago were thought to be inviolate to the scalpel. Thousands of lives are now saved and thousands of people rescued from becoming invalids.
The methods of treating germs have changed very materially since Sir Joseph Lister first announced his antiseptic treatment and showed the way to a new era in surgery; but the principles are much the same
Some germs have been found to be innocuous, even on wounded surfaces; others are deadly poisons. Some germs cause one kind of disease, some another; some are even antagonistic to others. They are all endowed with great resistance to ordinary medicines and are capable of propagation under adverse circumstances; they are contagious and infectious, and when carried from one person to another cause their specific disease to start up. The socalled bloodpoison is a general name for many distinct varieties of germdisease.
It matters not whether a simple wound is to be dressed, a leg amputated or a woman delivered, the one essential thing above all else which protects life and allows the wounded surface to heal is to make a clean field, to render the surfaces aseptic.
Aseptic. Septic. These are two terms which are daily becoming the common property of the laity: the former means without poison, germfree, or surgically clean ; the latter means poisonous, germladen, surgically dirty. Let it not be supposed that the flesh looks to the eye differently in these two conditions, it is not so necessarily. These bacteria are so minute that if a single rodbacillus were enlarged fifteen hundred times it would then only reach across the head of a pin. Nor is their virulence in proportion to their apparent numbers, for in twentyfour hours a single germ may multiply to sixteen and onehalf millions!
Surgical cleanliness is surgical morality, and consists not merely in washing off the rough, visible, outside dirt, but in rendering everything which can possibly touch the wound, directly or indirectly, germfree. This condition is called asepsis; when, however, germs have entered the wound and the consequent changes due to germ life have developed, then the condition is called sepsis.
Antiseptics. The important and practical question then is, how are these germs killed and how is the wound rendered aseptic ? Lister discovered in carbolic acid a germicide of no mean power, and even today this acid is most extensively used for the cleansing of wounds and instruments. This process of killing germ life is called sterilization.
After carbolic acid came numberless other drugs, such as corrosive sublimate, phenyl, sulpho naphthol, etc. Of this group corrosive sublimate is by far the most potent: it may be used in very weak solutions as one part to three, five, or even ten thousand of water.
Heat. By far the simplest, safest, and most economical method of sterilization is by means of heat, either in the form of boiling water, dry oven heat, or steam. Whatever can be baked for an hour at 140° of heat, or whatever can be steamed for an hour, and whatever can be boiled five minutes without impairing the integrity of the object sterilized, can be rendered absolutely sterile. Germs and their spores, which latter are more tenacious of life than the former, yield readily to boiling water in a few minutes; while some germs of the most virulent type may soak for hours in a tolerably strong solution of the chemical sterilizers without being killed. The tendency of the present is to substitute these natural means of sterilization for the chemical germicides.
Antitoxins, Serums and Vaccines.
RECENT studies have resulted in. great discoveries in Specific Therapy, as it is called. One method aims to assist the natural forces of the body in their struggle against invading germs; first, by applying “serums " which may be antitoxic or antibacterial in nature; the former being produced by repeatedly injecting perfectly healthy animals with increasing doses of the toxin or poison excreted by the germ, until there is developed an overwhelming number of antibodies or neutralizing products; the latter being made by injecting the germs themselves into animals. In both cases the resulting serum contains the antibodies of the germ in question. These serums are used in three ways: subcutaneously, which is the slowest method; intramuscularly, which is the one most often used; and intravenously, which is the most rapid method. In critical cases the serum is sometimes injected intraspinally.
Another method is by the injection of " bacterial vaccines," or “bacterins " as they are more properly called. Bacterial vaccines are sterilized, standardized suspensions of bacteria in normal salt solutions. They are sterilized by heating to 55 degrees or 60 degrees C. for one hour; standardized by counting; and preserved with cresol. They are administered subcutaneously, and the system is stimulated to form specific antibodies, a process which goes on for some time after inoculation, so that the acquired immunity from bacterins lasts longer than that which follows the use of serums. In the case of serums the antibodies are supplied to the patient; in the use of bacterial vaccines the patient develops his own antibodies. In other words, if the disease is active, serums should be injected; if it is desired to obtain protection from future attacks, bacterins should be employed.
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