Bacteria In Surgery
( Originally Published 1897 )
In no line of preventive medicine has bacteriology been of so much, value and so striking in its results as in surgery. Ever since surgery has been practised surgeons have had two difficulties to contend with. The first has been the shock resulting from the operation. This is dependent upon the extent of the operation, and must always be a part of a surgical operation. The second has been secondary effects following the operation. After the operation, even though it was successful, there were almost sure to arise secondary complications known as surgical fever, inflammation, blood poisoning, gangrene, etc., which frequently resulted fatally. These secondary complications were commonly much more serious than the shock of the operation, and it used to be the common occurrence for the patient to recover entirely from the shock, but yield to the fevers which followed. They appeared to be entirely unavoidable, and were indeed regarded as necessary parts of the healing of the wound. Too frequently it appeared that the greater the care taken with the patient the more likely he was to suffer from some of these troubles. The soldier who was treated on the battlefield and nursed in an improvised field hospital would frequently re-cover, while the soldier who had the fortune to be taken into the regular hospital, where greater care was possible, succumbed to hospital gangrene. All these facts were clearly recognised, but the surgeon, through ignorance of their cause, was helpless in the presence of these inflammatory troubles, and felt it always necessary to take them into consideration.
The demonstration that putrefaction and decay were caused by bacteria, and the early proof that the silkworm disease was produced by a micro-organism, led to the suggestion that the inflammatory diseases accompanying wounds were similarly caused. There are many striking similarities between these troubles and putrefaction, and the suggestion was an obvious one. At first, however, and for quite a number of years, it was impossible to demonstrate the theory by finding the distinct species of micro-organisms which produced the troubles. We have already seen that there are several different species of bacteria which are associated with this general class of diseases, but that no specific one has any particular relation to a definite type of inflammation. This fact made discoveries in this connection a slow matter from the microscopical standpoint. But long before this demonstration was finally reached the theory had received practical application in the form of what has developed into antiseptic or aseptic surgery.
Antiseptic surgery is based simply upon the attempt to prevent the entrance of bacteria into the surgical wound. It is assumed that if these organisms are kept from the wound the healing will take place without the secondary fevers and inflammations which occur if they do get a chance to grow in the wound. The theory met with decided opposition at first, but accumulating facts demonstrated its value, and to-day its methods have been adopted everywhere in the civilized world. As the evidence has been accumulating, surgeons have learned many important facts, fore-most among which is a knowledge of the common sources from which the infection of wounds occurs. At first it was thought that the air was the great source of infection, but the air bacteria have been found to be usually harmless. It has appeared that the more common sources are the surgeon's instruments, or his hands, or the clothing or sponges which are allowed to come in contact with the wounds. It has also appeared that the bacteria which produce this class of troubles are common species, existing everywhere and universally present around the body, clinging to the clothing or skin, and always on hand to enter the wound if occasion offers. They are always present, but commonly harmless. They are not foreign invaders like the more violent pathogenic species, such as those of Asiatic cholera, but may be compared to domestic enemies at hand. It is these ever-present bacteria which the surgeon must guard against. The methods by which he does this need not detain us here. They consist essentially in bacteriological cleanliness. The operation is performed with sterilized instruments under most exacting conditions of cleanliness.
The result has been a complete revolution in surgery. As the methods have become better understood and more thoroughly adopted, the in-stances of secondary troubles following surgical wounds have become less and less frequent until they have practically disappeared in all simple cases. To-day the surgeon recognises that when inflammatory troubles of this sort follow simple surgical wounds it is a testimony to his carelessness. The skilful surgeon has learned that with the precautions which he is able to take to-day he has to fear only the direct effect of the shock of the wound and its subsequent direct influence; but secondary surgical fevers, blood poisoning, and surgical gangrene need not be taken Into consideration at all. Indeed, the modern surgeon hardly knows what surgical gangrene is, and bacteriologists have had practically no chance to study it. Secondary infections have largely disappeared, and the surgeon is concerned simply with the effect of the wound itself, and the power of the body to withstand the shock and subsequently heal the wound.
With these secondary troubles no longer to disturb him, the surgeon has become more and more bold. Operations formerly not dreamed of are now performed without hesitation. In former years an operation which opened the abdominal cavity was not thought possible, or at least it was so nearly certain to result fatally that it was re-sorted to only on the last extremity ; while to-day such operations are hardly regarded as serious. Even brain surgery is becoming more and more common. Possibly our surgeons are passing too far to the other extreme, and, feeling their power of performing so many operations without inconvenience or danger, they are using the knife in cases where it would be better to leave Nature to her-self for her own healing. But, be this as it may, it is impossible to estimate the amount of suffering prevented and the number of lives saved by the mastery of the secondary inflammatory troubles which used to follow surgical wounds.
Preventive medicine, then, has for its object the prevention rather than the cure of disease. By showing the causes of disease and telling us where and how they are contracted, it is telling us how they may to a large extent be avoided. Unlike practical medicine, this subject is one which has a direct relation to the general public.
While it may be best that the knowledge of curative methods be confined largely to the medical profession, it is eminently desirable that a knowledge of all the facts bearing upon preventive medicine should be distributed as widely as possible. One person can not satisfactorily apply his knowledge of preventive medicine if his neighbour is ignorant of or careless of the facts. We can not hope to achieve the possibilities lying along this line until there is a very wide distribution of knowledge. Every epidemic that sweeps through our communities is a testimony to the crying need of education in regard to such simple facts as the source of infectious material, the methods of its distribution, and the means of rendering it harmless.