By DR. ROBERT T. MORRIS.
Dr. Robert T. Morriss book, Fifty Years a Surgeon, which was reviewed in the July issue of this magazine, contains lessons of the greatest value, both to medical men and laymen. His views on microbes and the abuse of germicides are of outstanding importance and value and they should be read with the greatest attention, coming as they do from a man of the greatest practical experience in surgery. I am sure that many of the readers of this magazine will wish to read the book, and it is well worth buying. It is published by Geoffrey Bles at the very reasonable price of 10s. 6d.
Inimical microbes as well as body cells are composed of protoplasm. Both are simple in form and structure but highly organized chemically, and in the course of evolution have come to be the peers of each other as a result of the struggle for existence. In Natures eyes, “one is just as good as the other”, and both have a right to live.
Anything which is destructive to the protoplasm of microbes is likely to be destructive to the protoplasm of body cells as well. Germicides, which were introduced into our armamentarium during the Third Pathologic Era in surgery, have done an enormous amount of harm when employed without knowledge of the fact that they are injurious to body cells. Many germicides killed not only inimical microbes, but also those body cells which should have been left physically free to resist the entrance of microbes of any sort.
In addition to the use of germicides, detailed cleansing of wounds which had for its purpose the removal of products of infection sometimes exhausted the natural store of energy of the patient and left him less well equipped for taking up his personal cell fight against microbes. Further than that, our confidence in measures for securing asepsis and antisepsis –together with improved method in anaesthesia– led us to forget that when operating we were at work upon a living, sentient organism.
Operations which were conducted speedily were held to be carelessly-performed operations because of neglect of petty technical details. Operations conducted through short incisions were held to be incomplete because “they failed to expose all of the pathology”.
Every test supported my hypothesis; the patient, on the whole, is his own best antiseptic.
Unless the reader chanced to be on the scene at that period he cannot readily appreciate how radical this proposition was.
In the nineties it was customary for surgeons to treat cases of appendicitis in which there was infection of the peritoneum by making long incisions which caused shock. Incisions suitable for killing bears were being applied to weak patients. Surgeons made multiple incisions for purposes of drainage and these also caused shock. At that time gauze-packing and large drains were used in great quantity. The mere presence of such foreign lumbar in the abdominal cavity brought on shock and prevented the patient from readily summoning his own physiological resistance factors.
I asked the profession what would happen if ten hearty policemen were to be brought from their beats to the hospital and a yard of gauze inserted into the peritoneal cavity of each one of them. Would they be doing as well as expected next morning? Yet this was accepted treatment for abdominal infections for a while. Patients sometimes had to be given an anaesthetic when adherent gauze was removed for change of dressings.
In addition to ordinary packing and drains, iodoform gauze was commonly used, and this had a special death-rate of its own because of insidious iodoform poisoning — the symptoms of which are so like those of sepsis that deaths were set down to the account of sepsis when really due to iodoform. A well-known surgeon told me that he had not seen a case of iodoform poisoning in his wards. I seemed to recognize at least one as we went through, and persuaded him to have urine examinations made. To his great surprise, we found three such cases in that one ward.
It is almost impossible to persuade nurses and assistants to avoid wiping or washing a healing wound. They are impelled by a love for gross cleanliness which would appeal to kitchen maid. Fourth Era surgery recognizes that pus on the surface of a healing wound contains few if any harmful bacteria. If it is likely to macerate new repair cells we may apply pressure over a perforated waterproof protective covering which guides epithelium cells instead of entangling them as gauze does.
Dawbarn demonstrated that pus could not all be removed, anyway. He poured milk into the abdominal cavity of a cadaver and then tried to get it completely out. It cannot be done, but such an important experiment attracted almost no attention at the time.
Enormous damage was being done to the endothelial layer of the peritoneum by the cleansing methods. One single layer of cells upon peritoneum as upon skin is all that stands primarily between us and microbic disaster. The single layer of endothelium cells or of epithelial cells are the thin birch bark gets a hole in it it must have help quickly. When we get a hole in our epithelium or endothelium. Nature rushes help to our single layer of protecting cells and plugs the hole.
Operations which might have been completed in twenty or thirty minutes were often extended to an hour or even two hours in duration in order to allow perfection of operative technique. Meanwhile, like peas rolling out of a hole in a bag, energy granules were going out of the patients brain and nerve cells. But we did not realize that the central nervous system was being injured until Crile led in the telling about it.
Neither did we fully understand that all of the machinery of the ductless glands, arranged by Nature for purposes of meeting infection and conducting repair, were also being thrown out of gear by operative surgical shock.
Surgeons were overlooking the fact that every man would inevitably die as the result of a pin-prick were it not for the resistance to microbic invasion which was offered by his protecting body cells. I noticed that ability to resist infection was greatest in pin-prick cases, and that resistance diminished proportionately as a wound was larger than a pin-prick.
A natural deduction followed — the nearer we could bring a surgical operation to pin-prick proportions the better the chances of that patient for meeting infection with his own internal resources. Step by step I began to make shorter single incisions. Gradually I omitted pads “for protecting the peritoneum”, and strove to do away with extensive drainage apparatus, even when wide infection was present.
Examination of purulent material in these cases showed it to be frequently almost sterile. Invading bacteria were at work chiefly in the tissue rather than in large collections of fluid, no matter how malodorous the latter might be. The odour was that of sulphur alcohols or sulphurated hydrogen due to the presence of various microbes, most of which were little more than saprophytes.
When I spread purulent material over the normal peritoneum in the course of separating extensive adhesions, I noticed that it did not excite peritonitis. On the contrary, the peritoneum in the vicinity had called out a protective leucocytosis, an extremely significant fact. It seemed best not even to remove purulent material that had become spread in the vicinity. This avoided shock.
Recently I happened to step into an operating-room where a man of good surgical reputation had an appendix case with abscess. He needlessly made an incision long enough to allow him to pack off the area with gauze in order to prevent pus from getting upon the peritoneum. He then separated a heavy mass of dark, thickened omentum covered with lymph exudate in spots. He spoke of it as looking gangrenous and excised it– an extremely bad fault in technique, because it was loaded with protective materials.
The time expended upon removing it meant extra shock for the patient, and a long, raw surface at the line of incision in the mesentery was extremely inviting for post-operative bowel adhesion; a very risky thing. After evacuating the abscess and removing a perforated appendix he inverted the stump of the appendix. This was a dangerous as well as unnecessary procedure, because sutures in the caecum would be almost certain to tear out if it subsequently ballooned; and secondary abscess or worse would then result. He next cleansed the abscess cavity thoroughly– more time and force expended upon unnecessary technique.
Then the whole area was sponged with an antiseptic solution which, coming in contact with the exposed peritoneum, would be practically certain to cause peritoneal adhesions. The peritoneal margins were then closed with chromic catgut which would remain for a long time and cause more adhesions. He should have used fine plain catgut. A small drain was properly inserted and this, to my mind, was the only right step in the entire process. He did not suture all muscle planes separately, and the patient would be almost certain to develop a hernia later.
His operative style and aseptic management of the case were perfect. This surgeon would almost certainly have a death-rate of at least 15 per cent.– in a class of cases that should give less than 5 per cent.
The most ancient treatment of insanity we know was the Hippocratic practice of using a strong purgative in the shape of hellebore. It is certain such a practice has remarkably good and curative effects in many cases.
Few things are more evident in most acute cases and many chronic forms of mental disease than derangements of digestion, of the action of the bowels, and of the hepatic (liver) functions. The tongue will very often be found coated and furred. It tends frequently to be dry, this morbid condition being shared by the mucous membrane of the mouth and throat. It will be found that in most cases of melancholia the bowels are inactive and are often obstinately constipated. Frequently the stools are devoid of bile, while the colour of the skin and of the conjunctivae is muddy and yellowish.
Of late years the opinion has become strong and widespread that the contents of the bowels may become very septic, and that catarrhal conditions of the stomach and bowels frequently result from this cause.
Dr. Ford Robertson, of the Scottish Asylums Pathological Laboratory, has lately astonished those of us who have seen most symptoms and treatments of insanity, by drawing attention to the enormous multiplication of micro-organisms over the surface of the mucous membrane of the stomach, duodenum, and small intestine, in general paralysis. As the result of those clinical and pathological facts, it may be said that purgatives have lately “come in again”.– DR. T. S. CLOUSTON, An Index of Treatment.