of Lord Lister (1827-1912), whose work naturally dovetails into that of
Pasteur. Lister’s attention was first called to the work of Pasteur in
1865. But Pasteur’s views on the life of micro-organisms came to a mind
that had been prepared for them. Lister had had, moreover, a long and
varied surgical experience and had been present at the first operation
performed in England under Ether anaesthesia in 1846.
At that time and for long after, Surgery was cursed by the constant
fear of sepsis. A vast amount of death and suffering was due to this
cause, and surgeons were reluctant to perform many operations that
we should now regard as trivial. Lister’s first attempt to make any
scientific analysis of the septic state is to be found in a paper by
him on _The Early Stages of Inflammation_ (1853). He showed that the
effects of irritation on the tissues are twofold. Firstly, there is
a dilatation of the arteries which is developed through the nervous
system. Secondly, there is an alteration in the tissues on which the
irritant acts directly. This alteration imparted, as Lister thought,
an adhesiveness to both the red and the white corpuscles, making them
prone to stick to one another and to the walls of the vessels, and so
giving rise to stagnation of blood and ultimately to obstruction.
Some years before (1847) A. V. Waller (1816-1870), a pupil of Magendie,
had shown that during the process of inflammation there is an active
migration of white blood corpuscles through the walls of the capillary
blood-vessels. Waller’s observations attracted but little attention at
the time. They were, however, amply confirmed in 1878 and the following
years by the German pathologist Julius Cohnheim (1839-84), a pupil of
Virchow. Cohnheim showed that this process of migration of white blood
corpuscles is the essence of inflammation and that when inflammation
goes on to suppuration the pus that is formed consists largely of white
blood corpuscles in a dead and disintegrating state.
Irritation, and the reaction of the body against it, ‘inflammation’,
are encountered in all injuries in which the healing is not direct
and healthy. It was those cases of injury in which the healing was
indirect and unhealthy which then formed the surgeon’s chief problem.
Of these there are a variety, now rare, then very common and fatal,
as Blood-Poisoning, Erysipelas, Pyaemia, Septicaemia, Hospital
Gangrene, and that form, then so common as to be almost normal, simple
suppuration of a wound.
About 1861 Lister began to teach publicly that the occurrence of
suppuration in a wound is determined ‘simply by the influence of
decomposition’. The nature of decomposition was revealed to him by the
writings of Pasteur. From him he learned that putrefaction was, in
fact, a fermentation, and that it was caused by the growth of minute
microscopic organisms borne by the air. It was generally supposed that
air was the cause of sepsis, and precautions were taken to exclude it
from wounds. But Lister now saw that not air but that which it carried
was the mischief-maker.
The general course of action was now clear to him. As a laboratory
proposition the destruction of the organisms of the air was simple. The
problem was to exclude them from wounds during and after operation. The
solution of that problem developed as ‘Antiseptic Surgery’, which later
became ‘Aseptic Surgery’. At first he paid most attention to air, as
the source of infection. He recognized, however, that he must also deal
with the germs present in the wound and on his hands. Of the methods
available for ridding the air of its germs, viz. heat, filtration, and
chemical action, he chose the last.
At that time carbolic acid was in use as a means of treating sewage. At
first, therefore, Lister tried lint soaked in crude carbolic. This he
found liable to cause superficial sloughing and death of the tissues.
He next obtained a purer acid, using a solution in oil. A putty formed
of common whitening and a solution of carbolic acid in linseed oil was
used as a dressing. He adopted later a system of spraying the part
during operation (Fig. 109).
[Illustration:
FIG. 109. THE ‘DONKEY ENGINE’, an apparatus designed and used by Lord
Lister to maintain a carbolic spray over a part during operation. The
engine is worked by the up and down movement of the handle to the right
and the spray is delivered through the tube to the left.
]
When Lister began his work, amputation of a limb was a very fatal
operation. Yet it had to be performed in most cases of severe fracture
in which the bone was exposed because, without it, death from sepsis
was almost certain. The improvement in Lister’s own records of
amputation, incident upon his adoption of the antiseptic method, is
well brought out by his own figures:
_Years._ _Cases._ _Recovered._ _Died._ _Mortality._
1864-66 35 19 16 43% without antiseptics
1867-70 40 34 6 15% with antiseptics
These results were considered extraordinarily good in their day. It
is an index of the further advance since Lister’s first attempts that
results ten times as good would now be regarded as unsatisfactory.
Moreover not only has the further development of Lister’s method
rendered amputation safer, but also it has enabled the surgeon to treat
many cases without amputation, when before he would have been compelled
to resort to that measure.
Lister first recorded his observations on the antiseptic system of
surgery in 1867. Apart from the technical advances that he then set
forth, he recorded also many new pathological facts that have since
proved of great practical importance. Thus he showed that an uninfected
clot, if undisturbed, can become organized into a living tissue, and
that a piece of dead bone may be absorbed in an aseptic wound. These
are now matters of common knowledge, but then they were instrumental
in introducing a radically new outlook.
Lister gradually perfected his technique, chiefly in the direction of
using milder antiseptics and adopting heat for the sterilization of
instruments and dressings. The antiseptic system was given its military
application in France during the war of 1870. It was soon taken up also
by German surgeons. The history of surgery since Lister’s day has been
very often told. An important element in it is the gradual supersession
of ‘antiseptic’ by ‘aseptic’ methods (p. 248).
The Listerian system, in rendering surgery safer, had also the
effect of opening up many fields of operation that had previously
been regarded as impracticable. Especially is this the case with
abdominal surgery, which effectively dates from the introduction of
the antiseptic system. Lister was often misunderstood and some of his
contemporaries, and some even of those who opposed him, were really
practising his system without knowing it.
Among the most important reactions of antiseptic surgery was that upon
the conduct of labor. Here Lister had a predecessor, as he gladly and
generously acknowledged. This was the unfortunate and almost insane
Viennese genius, Ignaz Semmelweis (1818-65). At the great lying-in
hospital at Vienna in which he was an assistant the death-rate at one
time rose to thirty per cent., the so-called ‘puerperal fever’ being
the active cause. The women were attended by students or physicians
who were visiting the post-mortem room. Semmelweis showed that the
infective material that conveyed the fever was brought by the hands of
the operator from the dead bodies and he showed that puerperal fever
was caused by decomposed animal matter. By insisting on the hands
of the operators being sterilized, Semmelweis succeeded in 1846 in
enormously reducing the mortality. After the acceptance of Lister’s
antiseptic system the methods of Semmelweis were universally introduced
into the practice of Midwifery. Another predecessor of Lister was
Oliver Wendell Holmes. As early as 1843 he pointed out that the
mysterious ‘puerperal fever’ was contagious, and carried by the hands
of the operator. He suggested precautions not dissimilar to those of
Semmelweis.
[Illustration: FIG. 109A. OPERATING TABLE USED BY LORD LISTER in the
Glasgow Royal Infirmary.]
§ 9. _Some Modern Surgical Advances._
Among the most capable surgeons of Lister’s own day was Thomas Spencer
Wells (1818-97) of London. This great operator had been opening the
abdomen successfully for certain conditions since 1858. By 1867 his
methods were approaching the Listerian. Under Lister’s inspiration
he further improved his technique and did more than any other man to
raise the possibilities of abdominal surgery. Spencer Wells stands
out for the extreme simplicity, directness, and effectiveness of
his methods (Fig. 111), and for his exceptionally conscientious care
as an operator. His name is commonly attached to an instrument of
his invention of catching the bleeding ends of cut blood-vessels.
The familiar ‘Spencer Wells forceps’ is at this day probably more
frequently used than any other surgical instrument (Fig. 110).
[Illustration: FIG. 110. ‘SPENCER WELLS FORCEPS.’]
[Illustration:
FIG. 111. SPENCER WELLS performing an abdominal operation about 1870.
The picture illustrates the extreme simplicity of the methods of this
great surgeon. It also shows a method of administering chloroform. Air
is pumped through a bottle into a mask held at a variable distance from
the face of the patient.
]
Since the time of Lister many branches of Science have contributed to
the development of surgical technique. No addition to the surgical
armory has, however, been more important than that made by the
physicist Wilhelm Conrad Röntgen (1845-1923). In 1895 he found that
when an electric discharge passes through a high vacuum rays are
emitted that are far more penetrating than ordinary light. These rays
have since then been placed in series with light rays, ultra-violet
rays and infra-red rays, and it has been shown that they differ from
these only in their wave-length. The surgical application of the
Röntgen or X-rays was at once made to the examination of bone. Since
then the more accurate knowledge of the properties of these rays
has made them of value in exploring almost every organ of the body.
Radiography is now constantly applied in the diagnosis of medical and
surgical conditions of the organs of the chest and abdomen.
The more dramatic achievements of modern surgery, the drastic
operations that surgeons are now able to perform on the great cavities
of the body--head, chest, and abdomen--have attracted much public
attention. Nevertheless few surgical advances have relieved so much
suffering and disability as the unsensational development in the
treatment of fractures.
After the advent of Listerian methods the technique of the treatment
of compound fractures was gradually perfected. Simple fractures--which
are far commoner--continued, however, to be treated with splints in
the traditional fashion. Plaster of Paris bandages, which came into
wide use in the ’seventies, were some improvement; but prolonged
immobilization of a limb, in either splints or plaster bandages, always
involves much subsequent pain and stiffness, lasting, at best, for
months. To obviate this, Massage--a practice of immemorial antiquity
in Folk Medicine--had been introduced into Surgery in the sixteenth
century by Ambroise Paré (pp. 92-94). The subject was little heard
of till the last thirty years of the nineteenth century. The pioneer
was the Dutch surgeon Johann Mezger (1839-1900), through whom some
scientific advance was made.
[Illustration: FIG. 112. AN OPERATION IN THE SIXTEENTH CENTURY.
The semi-conscious patient lies face downward on an elaborately
carved bed. The bearded surgeon, dressed in his ordinary clothes, is
trephining his skull and is rotating the trephine between his hands.
Against the side of the bed lounges a gallant to whom a servant brings
refreshment. In the background are two women assistants. A male
assistant is spreading a plaster and another warming a towel over a
brazier. Note that all present, surgeon, nurses, assistants, &c., wear
their ordinary dress. No arrangements are made for washing. In the
foreground is a cat playing with a mouse. ]
The introduction of X-rays into Surgery made for very accurate
diagnosis of the state of fractures. It has thus gradually become
possible to treat a large proportion of these injuries without
immobilization either by splints or plaster. In many cases the injured
limb is merely held in correct position between sandbags and massage
used from the first. Much stiffness and disability is thereby avoided
and the length of the period of treatment greatly shortened. The rise
of a class of scientifically trained Masseurs has made possible a wider
application of this valuable curative procedure.
Improvements in methods of operation have been very numerous during
the last generation. Many can be appreciated only by those with
technical knowledge. In 1886 Ernst von Bergmann of Berlin (1836-1907)
introduced steam sterilization of dressings and thus moved toward the
replacement of antiseptic by aseptic methods. W. S. Halsted, then
of New York, had been working to the same end. In 1890, finding it
impossible to sterilize the hands completely, he introduced the rubber
gloves now universally employed by surgeons during operations. Much
important work in experimental surgery has been done by Alexis Carrel
of New York (1873-) and some of his laboratory methods have become
available in surgical practice. The technique of abdominal surgery has
been greatly advanced by many workers, important among whom are J. B.
Murphy (1857-1916) of Chicago and the brothers Charles and William Mayo
(1865 and 1861) of Rochester, Minnesota. The surgery of the brain was
prosecuted in England by Rickman Godlee (1849-1925), the nephew and
biographer of Lister, by Victor Horsley (1857-1916), and above all by
William Macewen (1848-1926), a successor to Lister’s chair at Glasgow
and one of the finest exponents of Listerian methods. The surgery of
the nervous system in general, and that of the brain in particular, has
been carried to extraordinary refinements in America by Harvey Cushing.
There can be no doubt that during the twentieth century advances in
Surgery have been more important and more numerous in the United States
than in any other country.
[Illustration: FIG. 113. AN ABDOMINAL OPERATION UNDER MODERN CONDITIONS
Only those directly concerned with the operation are present in the
room. All wear aseptic clothes and aseptic rubber gloves. Every source
of infection is guarded against and all breathe through masks. The
patient is covered by aseptic cloths and only the part operated on is
exposed.
]
§ 10. _Bacteriology becomes a special Science._
We have seen the microbic view of the origin of disease demonstrated
as a reality by Pasteur (pp. 224-35) and extended to special disease
conditions by him and by Koch (pp. 229-32). While the French observer
stood above all men for the clearness and steadiness of his vision and
for his persistence and resource in following what he had seen from
afar, his German colleague had a genius for visualizing particulars
and for adapting mechanical devices and scientific discoveries to
particular ends. Koch thus vastly improved and elaborated the methods
for detecting and examining minute organisms. The significance of his
results was at once recognized, but the complexity of the technique
involved and the time and training necessary demanded the elevation of
the subject into the position of a special science.
Though but fifty years old, the science of Bacteriology has itself
undergone repeated subdivision. Noteworthy though the results of this
process of constant subdivision have proved, it must be emphasized
that the state of scientific subdivision cannot be final, and is
indeed without meaning unless it lead to a subsequent synthesis--an
event which we still await. It is the general Laws reached by these
special sciences that are philosophically important, and the specialist
himself is often ill-placed and ill-equipped for the estimation of the
true significance of such Laws. The philosophic thinker who deals with
generalities and centuries must often be content to pass the details in
silence. Nor is this true only of the professed philosopher. It applies
no less to the philosophical physician. It is his task to try to see
life steadily and see it whole. He must think both in terms of the
individual life and of the community life, and for him the results of
the bacteriologist, the physiologist, and of all their colleagues are
as means to an end. It is from this standpoint that we should seek to
visualize the fruits that bacteriological science in this last age has
laid at the feet of humanity.
With Koch’s work on Anthrax in 1876, on the bacteria that commonly
infect wounds in 1878, and with his great discovery of the bacillus
of Tuberculosis in 1882, the study of the infective diseases entered
on a new stage. The enemy had been seen and was now known for what he
was. The bacteriologist had succeeded in making prisoners. These had
been isolated and made to live in test-tubes. Moreover, the organisms
had been compelled to dwell alone without mixing with other species.
They had been obtained, as bacteriologists say, in ‘pure cultures’,
and delicate methods of detecting and differentiating them had been
developed. With a pure culture in his hands, the bacteriologist can
determine the influences favorable or unfavorable to the growth of the
disease organism, and he can investigate conditions that can exalt,
destroy, or modify its activity (p. 233).
An important series of criteria established by Koch have remained the
tests by which the disease-bearing character of these organisms can be
established. To prove that an organism is the inseparable cause of any
disease we need to demonstrate:
1. The constant presence of the organism in every case of the disease.
2. The preparation of a pure culture, which must be maintained for
repeated generations.
3. The reproduction of the disease in animals by means of a pure
culture removed by several generations from the organisms first
obtained.
These conditions have been fulfilled for many diseases. Evidently the
third test can be applied only in conditions to which animals other
than man are susceptible. Now in this matter the organisms that produce
disease vary greatly. Some, for instance those of Anthrax, are easily
conveyed to a variety of species of animals; others, for instance
those of Syphilis, are with difficulty conveyed to very few species of
animal; yet others, for instance human Malaria, cannot be conveyed to
any animal save man.
Some light is thrown on the life-history of the second and third
classes by recent discoveries. The science of Comparative Pathology,
that is the knowledge of the relations of the diseases of different
species of animals, is of very recent growth. It has already
demonstrated, however, the existence of organisms bearing some
resemblance, for instance, to those of human Syphilis and human Malaria
as the cause of disease in animals. By studying the life-history of
these organisms in animals and by studying their effect on animals,
valuable side-lights have often been thrown on the allied diseases in
man. Moreover, in exceptional cases and in some special diseases, it
has been possible to convey a disease experimentally to man.
A second important factor has gradually come into prominence with the
extension of bacteriological knowledge. It is evident that not all
men are subject to all human diseases. Even in the most destructive
epidemic there are some that escape. These lucky ones may be naturally
‘immune’. Many diseases, such as Measles, seldom recur in individuals
who have been infected, so our lucky ones may thus have an ‘Acquired
Immunity’.
The general nature of Immunity we shall presently discuss (p. 259),
but we note here that Immunity may be relative or absolute, and may,
moreover, vary according to the circumstances of the individual. Thus,
for instance, a well-fed, well-housed person of temperate habits,
living an open-air life, is unlikely to develop consumption. Restrict
his diet, confine him in an office, deteriorate his mode of life,
and he may well fall a victim to it. The investigation of facts such
as these on a large scale has demonstrated that the _soil_ in which
disease grows is of no less import than the _seed_ from which it grows.
The problem of disease causation is thus immensely complex. We are
only just beginning to draw up general laws on the subject, and in
approaching it we are beyond the frontiers of our positive knowledge.
Turned back from this difficult borderland, we must content ourselves
with surveying a part of the better-known territory and considering a
few specific bacteriological achievements. These we may now consider
under the headings of the diseases associated with them.
§ 11. _Some Important Bacteriological Results._
_Diphtheria_ is a disease for which physicians now habitually demand
a bacteriological diagnosis. Bretonneau of Tours (p. 185), working on
clinical and post-mortem material, and without the use of a microscope,
was able to distinguish Diphtheria as a specific disease (1826). Half
a century later (1883) Edwin Klebs (1834-1913) of Zürich, a pupil
of Virchow, described the specific organism of the disease. In the
following year Friedrich Loeffler (1852-1915), a Prussian and an
assistant of Koch, succeeded in cultivating it. The organism has since
been known as the ‘Klebs-Loeffler Bacillus’. Its study has thrown much
light on the nature of bacterial action in general and has, moreover,
led to important therapeutic developments (p. 263).
Of all diseases destructive of human life, none is so dramatic as
_Plague_, the scourge of mankind throughout history. The bacillus
of Plague was discovered independently by the Japanese Shibasaburo
Kitasato (_c._ 1860-), a pupil of Koch, and by the Frenchman Alexandre
Yersin (1863-), a pupil of Pasteur, during an epidemic at Hong Kong
in 1894. These two observers cultivated the organism and reproduced
the disease by inoculation of pure cultures in animals. It had long
been observed that outbreaks of a deadly disease of rats and mice
were liable to precede Human Plague. These ‘epizootics’ which precede
‘epidemics’ are now known to be due to the bacillus of Plague. A mass
of evidence has been collected to show that the normal carrier of
the Plague infection is the rat flea. This knowledge has led to the
formulation of effective measures for the control of Plague. These
measures are based on the wholesale extermination of the rat population
which harbors the infective fleas. The study of the Natural History
of the Plague Bacillus has also led to prophylactic measures for the
safety of individuals.
[Illustration:
FIG. 114. BACILLI OF DIPHTHERIA FROM A CULTURE. Highly magnified. In
cultures these bacilli are liable to degenerate into thick club-shaped
forms several of which are here seen.
]
[Illustration: FIG. 115. BACILLI OF PLAGUE FROM A CULTURE. Highly
magnified.]
_Malta Fever_ is a disease of much wider distribution than its name
implies. Not only is it found throughout the Mediterranean area, but
it is also encountered in China, South Africa, and parts of both North
and South America. It is a long, tedious and wearing disease, and
though the mortality from it is low, yet it was at one time one of the
main causes of disability in the British army at Malta. In 1887 an
English military surgeon, David Bruce (1855-), succeeded in cultivating
a characteristic bacillus from the spleen of a patient dead of the
disease, and he established its causal relation to Malta Fever. In 1904
its mode of propagation was studied by a British Government Commission.
The goat was shown to be the normal host of the bacillus, and in Malta
50 per cent. of these animals were found to be infected. The disease,
it was discovered, is usually transmitted by goat’s milk. The knowledge
has led to the application of very effective precautions (Fig. 116).
[Illustration: