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are carried into wounds, abscesses, or nature of what Lord Palmerston called other cavities by the hands of those “matter in the wrong place;" and this who minister to the patient, and by in- something it is the aim of modern surstruments, dressings, clothing, and by gery to keep out, whereas to the men of water, unless means are used to destroy only a generation ago it was an unconthem. The vital importance of doing sidered trifle. The elaborate ritual of tais, and the way in which it could be purification by sprays of carbolic acid done, were indicated by Joseph Lister, a and the manifold dressings, as compliman who is justly venerated by the cated as My Uncle Toby's fortifications, whole medical world, and whom his by which at first it was sought to exsovereign has delighted to honor in a clude the enemy from the living citadel, manner hitherto without precedent in have been discarded as cumbrous and this country. His work forms, without unnecessary; but whatever change may excepting
the discovery of be made in the details of Listerism, the anesthesia, the most conspicuous land- Listerian principle of safeguarding mark in surgical progress; indeed, it is wounds from every possible source of no exaggeration to say that the history contamination will stand forever as the of surgery now falls by a natural divi- foundation stone of scientific surgery. sion into two distinct eras: Before Lister The results of the application of the and After Lister.
principle are seen in every department Modern surgery dates from the intro- or surgical practice. The risks of surduction of the antiseptic treatment of gery have been lessened to such an exwounds. Thirty years ago the idea was tent that the statistics of most of the just beginning to settle itself into clear- greater operations before the antiseptic ness in the mind in which it was con- treatment came into general use are ceived; twenty years ago it was still now valueless for purposes of compariregarded by many “practical men” as a son. A few figures will serve to show figment of the scientific imagination; the difference. Till a comparatively but as the evidence became irresistible, recent period the proportion of cases in unbelievers one after another found sal- which death followed amputation of a vation. Now the doctrine finds vir- limb in the large city hospitals of Great tually universal acceptance.
at least one in three; years ago a doctor in Germany was pros. in a series of 2,089 cases collected ecuted and punished for some breach by Simpson it was as high as 1 in 2.4. of the antiseptic ordinance in an opera- In the Paris hospitals about the middle tion; and though we have not yet of the century the death rate after amreached that perfection of medical dis- putation was nearly one in two; in 1861 cipline in this country, the deliberate it was three in five, and a few years and persistent neglect of surgical clean- later it was estimated at fifty-eight per liness by a member of the staff of a cent. In Germany and Austria things public hospital would be certain to give were not much better; the published rise to strong protests on the part of his statistics of one most skilful surgeon colleagues.
show a proportion of deaths following The cardinal point in Lister's teach- amputation of forty-three to forty-six ing was that wounds will in the absence per cent. Nowadays such figures in the of any disturbing influence, constitu- practice of any hospital surgeon would tional or accidental, remain sweet and probably lead to an inquiry by the heal kindly, if contamination from proper authorities. without be prevented. The theory is A very large number of these fatalities that such contamination is caused by
was caused by septic diseases-that is to micro-organisms; in practice, it matters say, different forms of blood-poisoning nothing whether it is held to be due to due to contamination of the wound, germs or to dirt. It is certainly caused leading to constitutional infection. The by something foreign, something in the terrible frequency of such diseases a
few years ago may be judged from the that the average mortality rate after fact that among six hundred and thirty- amputations in a London hospital which one cases of amputation collected from from a structural and sanitary point of the returns of some London hospitals view leaves much to be desired, fell between 1866 and 1872, there were from twenty-seven in 1871 to about two hundred and thirty-nine deaths; eleven in 1890. Of six hundred and and of those deaths no fewer than eighty-seven cases of amputation pereighty-six were caused by pyæmia, a formed in a hospital in the North of Ennumber of others being due to septi- gland from 1878 to 1891 there was only caemia, cellulitis, and erysipelas. Con- eight per cent. of deaths; in the uncomservative surgery in hospitals was out plicated cases, taken separately, the of the question. Sir Charles Bell has mortality rate was no more than four left a vivid description of attempts in per cent. In a series of cases operated that direction in military practice in the on by several German surgeons of the pre-antiseptic era:
first rank, in the pre-Listerian era, the
average death rate was between thirtyIn twelve hours (after the infliction of a
eight and thirty-nine per cent.; in a gunshot wound of a limb] the inflam corresponding series, in which the antimation, pain, and tension of the whole
septic method was used, the mortality limb, the infiamed countenance, the bril.
was seventeen per cent. I have taken liant eye, the sleepless and restless condi
these statistics because they happen to tion, declare the impression the injury is inaking on the limb and on the constitu
be ready to my hand. A more brilliant tional powers. In six days the limb from array of figures in favor of the antisepthe groin to the toe, or from the shoulder tic treatment could, I have no doubt, be to the finger, is swollen to half the size of made by careful selection of cases. the body; a violent phlegmonous inflam- The facts which I have quoted, howmation pervades the whole; serous effu. ever, probably represent the plain truth, sion has taken place in the whole limb; In the operation for the radical cure and abscesses are forming in the great of hernia the results have been even beds of cellular texture throughout the
more striking. Twenty years ago this whole extent of the extremity. In three procedure was, on account of its fatalmonths, if the patient have labored through ity, considered to be almost outside the the agony, the bones are carious; the ab. scesses are interminable sinuses; the limb pale of legitimate surgery; now it is one is undermined and everywhere unsound: of the most successful of operations. and the constitutional strength ebbs to the
One English surgeon has performed it lowest degree.
seventy-two times, with two deaths; an
other one hundred and thirty-seven It was no wonder therefore that mili- times, with five deaths. An Italian tary surgeons as late as in the Crimean operator has a record of two hundred War went largely by "the good old rule, and sixty-two cases, with one death; a the simple plan” of amputating for French surgeon one of three hundred all wounds of the limbs involving in- and seventy-six, with two deaths. jury to bone at once, “while the soldier Quite recently an American surgeon has was in mettle.” In recent wars, by the reported a series of three hundred and use of antiseptic “first field dressings” sixty antiseptic operations for the radiand by subsequent treatment with jeal- cal cure of hernia, with only one death; ous regard for surgical cleanliness, it and in that case the fatal result was has been found possible to save a large found to be due, not to the surgical proproportion of limbs. In civil hospitals cedure, but to the anæsthetic. In the pyæmia is now almost unknown, and operative treatment of cancer of the hospital gangrene, formerly a justly breast Lord Lister's disciple, Professor dreaded scourse, is extinct.
Watson Cheyne, not long ago published As illustrations of the improvement a series of cases showing a measure of which has taken place in the results of success in dealing with that formidable amputations it need only be mentioned affection altogether unparalleled. Taking the received limit of three years ever, saw what others had not seenwithout recurrence of the disease as the namely, the true significance of these standard, he has been able to show a
facts. They taught him that the result of not less than fifty-seven per peritoneum was much more tolerant cent, of cures. Old statistics give the than it was believed to be, and in parproportion of "cures" after these opera
ticular that a clean incised wound of tions as five per cent., and even ten or
that membrane was as simple a matter twelve years ago it was no higher than and as free from danger as a like wound twelve or fifteen per cent. Part of Mr. of any other tissue. Cheyne's remarkable success is doubt- This simple observation had farless due to his very thorough removal of reaching consequences. Wells took the disease; but when due allowance is upon himself the task of bringing the made for this, a large part remains to be operation of ovariotomy, which, owing placed to the credit of the antiseptic to its terrible fatality, had fallen into treatment as making such drastic meas- utter discredit, within the sphere of ures feasible. It may here be stated orthodox surgery. Not long before he that, generally speaking, operations for turned his attention to the subject a cancer are more successful now than well-known surgeon had been threatthey were in the earlier part of her ened by a colleague with a coroner's inMajesty's reign; this is due not only to quest on any patient of his that should the rigid observance of surgical cleanli- die after the operation. Wells's first ness, but to a better understanding, and ovariotomy was performed in 1858, and in particular an earlier recognition, of the patient recovered. During the enthe disease, which gives the surgeon the suing six years he operated one hundred opportunity of interfering while there is times, with thirty-four deaths—a rate of yet time to prevent its spreading. mortality that would now be thought
In no department of surgery has appalling. He succeeded, however, in greater progress been made than in the placing the operation on a firm basis, treatment of diseases of the abdominal and as he gained experience he perorgans, and here, too, the way was pre- fected his procedure, so that his morpared, and the advance has been power- tality rate fell steadily till it almost fully helped, by the doctrine of surgical reached the vanishing point. It has cleanliness. The development of ab- been estimated that by this particular dominal surgery is, however, directly operation alone he added ten thousand due to the late Sir Spencer Wells more years in the aggregate to the lives of than to any other man. Wells began women who had the benefit of his skill. his professional career as a surgeon in By his teaching and example, moreover, the navy, and during the Crimean War he did much more than this. He proved he had opportunities of seeing men re
that the abdomen could, with proper cover from injuries caused by shot and precautions, be opened freely without shell which, according to the canons of fear, and thus laid the foundations of surgery then generally received, ought abdominal surgery in its modern develto have proved fatal. Till that time opment. The success of ovariotomy and for several years afterwards sur- opened men's eyes to the feasibility of geons had almost superstitious operations on other abdominal organs, dread of wounding or handling the and to the possibility of dealing with inperitoneum, the membrane which in- juries which before were believed to be vests the organs contained within the beyond the resources of surgical art. abdomen. Wells saw, as others had Soon the peritoneum, which had aforeseen, men who had been stabbed in the time been held in such awe, came to be abdomen so that their bowels gushed treated with familiarity-sometimes, it out brought to the hospital, where their is to be feared, with contempt. One intestines were washed and replaced, celebrated operator is said to have deand the wound stitched up, and in a clared that he thought no more of openshort time all was well again. He, how- ing the peritoneum than of putting his
hand into his pocket. At the present a region that was thought to offer no time no abdominal organ is sacred from room for further investigation, and thus the surgeon's knife. Bowels riddled showed the way to new methods of dealwith bullet-holes are stitched up success- ing with its diseases. To him, Mr. fully; large pieces of gangrenous or can- Lawson Tait, Mr. Harrison Cripps, and cerous intestine are cut out, the ends of Mr. Mayo Robson in this country; to the severed tube being brought into con- Czerny and Wölfler in Germany: and to tinuity by means of ingenious appli- Senn and Murphy in America, it is ances; the stomach is opened for the re- largely owing that the abdomen, which moval of a foreign body, for the exci- but a few years ago was the territory of sion of a cancer, or forthe administration the physician, has been transferred to of nourishment to a patient unable to the surgeon-to the great advantage of swallow; stones are extracted from the mankind. substance of the kidneys, and these That surgery could ever deal with the organs when hopelessly diseased are ex- abdominal organs in the manner just de tirpated; the spleen, when enlarged or scribed would have seemed to our predotherwise diseased, is removed bodily; ecessors in the earlier part of the gall-stones are cut out, and
queen's reign the baseless fabric of a tumors of the liver are excised. The vision. But the modern surgeon, clad in kidney, the spleen, and the liver, when antisepsis, as the Lady in “Comus" was they cause trouble by unnatural mobil- "clothed round with chastity," defies ity, are anchored by stitches to the the “rabble rout" of microbes, and dares abdominal wall; and the stomach has things which only a short time ago were been dealt with successfully in the looked upon as beyond the wildest same way for the cure of indigestion. dreams of scientific euthusiasm. It is Besides all this, many cases of obstruc- scarcely twenty years since the late Sir tion of the bowels, which in days not John Erichsen declared in a public advery long gone by would have been dress that operative surgery had nearly doomed to inevitable death, are now reached its furthest possible limits of cured by a touch of the surgeon's knife. development. He pointed out that The perforation of the intestine, which there were certain regions of the body is one of the most formidable complica- into which the surgeon's knife could tions of typhoid fever, has in a few never penetrate, naming the brain, the cases been successfully closed by opera- heart, and the lung as the most obvious tion; and inflammation of the perito- examples of such inviolable sanctuaries neum, caused by the growth of tuber- of life. Within the last fifteen years culous masses upon it, had been appar- the surgeon has brought each of these ently cured by opening the abdominal organs, which constitute what Bichat cavity. Among the most useful ad- called the “tripod of life," within his vances of this department of surgery sphere of conquest. In the brain the remust be accounted the treatment of the searches of physiologists such as Broca, condition known “appendicitis," Hitzig, Hughlings Jackson, and Ferrier which has been largely rescued from made it possible in many cases to deterthe physician, with his policy of laisser mine the exact seat of abscesses and faire, and placed under the more reso- tumors, and it was found that with the lute and more efficient government of use of antiseptic precautions the brain the surgeon. A New York surgeon not substance could be dealt with as freely long ago reported a series of one hun- as any other structure. In 1883 Prodred cases of operation for appendicitis, fessor Macewen of Glasgow operated with only two deaths. In the develop- with success in two cases of paralysis ment of the surgery of the appendix and and other nervous disorders caused by the intestine generally, a prominent pressure on the brain. A tumor was repart has been taken by Mr. Frederick moved from the brain by Mr. Godlee in Treves, whose researches on the anat. the ensuing year. Since then portions omy of the abdomen shed a new light on of the brain have been removed, and
growths have been excised from its sub- hardly be counted among the legitimate stance by Mr. Victor Horsley, who has triumphs of surgery. Wounds of the done much to develop this branch of lung can, however, be dealt with sucsurgery, and Professor von Bergmann cessfully on ordinary surgical principles. and other foreign surgeons have been Tuberculous cavities in the lung subbusy in the same field. It must, how- stance have been laid open for the purerer, be admitted that the results of poses of drainage, but the results have brain surgery, though brilliant from the not so far been particularly good. In operative point of view, have so far a series of one hundred cases of which been somewhat disappointing as a report is before me, five of the patients gards the ultimate cure of the disease. died as the immediate result of the In certain forms of epilepsy, in particu- operation, seventy died within two lar, which at first seemed to be curable weeks, and fifteen more in the next fort. by removal of the "cortical discharging night; "only in ten of the cases was any centre" in the brain which is the source benefit derived," and as to these the of the mischief, the tendency to fits has judicious reader will probably conclude been found to return after a time, and that the principal "benefit" was that the the last state of the patient has been operation was survived. In cysts and worse than the first. Still, the mere abscesses of the lung and in pulmonary fact that the brain has been proved to gangrene surgical treatment is more be capable of being dealt with surgi- successful. It does not seem likely, cally with perfect safety is in itself a however, that the surgeon will ever be very distinct progress; and our able to annex the lung to his dominion, means of recognizing the situation, however far he may extend his territory nature, and extent of disease in that in other directions. organ improve, there is ground for hope The heart naturally cannot be maile that the results of operative treatment so free with, even by the most enterpriswill be more satisfactory. It is by no ing surgeon, as the brain or the lung. means impossible that some forms of Yet within the past twelve months i apoplexy may yet come within the Norwegian practitioner has reported a province of the surgeon.
case which encourages a hope that even Other parts of the nervous system wounds of the heart may not be beyond have been brought within the range of surgical treatment. A man was surgical art. The vertebral column has stabbed in the region of the heart, the been successfully trephined, and frag- weapon entering the substance of that ments of bone pressing on the cord have organ, but not penetrating its cavity. been taken away in cases of fractured The wound in the heart wall was nearly spine; tumors have also been removed an inch in length. The patient was alfrom the spinal cord by Mr. Horsley most at the last gasp, but he was reand others. There is a steadily increas- vived. The heart was then exposed by ing record of
of intractable an operation which involved the reneuralgia, especially of the face, by moval of portions of the third and division or removal of the affected fourth ribs, and the wound nerve trunks; the Gasserian ganglion stitched. The patient lived for two has been successfully extirpated in des- days and a half. On examination after perate cases by Mr. William Rose, Pro- death the wound was found to be healfessors Thiersch, Angerer, and Krause, ing. It is clear, therefore, that in more M. Doyen, and others. The ends of cut favorable circumstances the man might nerves have also been re-united, and hare recovered. solutions of their continuity have been Of the advance in some other departfilled up with portions of nerve taken ments of surgery, only a passing menfrom animals.
tion can be made here. Thus "cutting.” In the lung, tumors, including locals which sisty years ago was the only ized tuberculous masses, have been re- means of dealing with stone, has now, moved, but these achievements can thanks to Bigelow, Thompson, and