Bacteriological Principles in Surgery

bacteriology. If he has not had this training, —and, unfortunately, it has not as yet been possible to secure it at the majority of medical schools,— he must accept and carry out in his work princi- ples which have been laid down by those who have had the opportunity of submitting their methods to the test of bacteriological criticism. Any one who has been trained in a bacteriological laboratory will have exalted ideas of surgical cleanliness, and cannot INCONSISTENCIES IN TECHNIQUE. ll fail to see the many inconsistencies that occur dur- ing the majority of operations. While these incon- sistencies may to many appear trifling, in reality they are only too often responsible for the introduction of infectious material into the wound. One would think that an operator, after taking every precaution to render his hands surgically clean, would avoid bringing them in contact subsequently with objects which have not been previously sterilized, and yet it is by no means uncommon to see those who are re- garded as “careful men” touching with their hands the face or hair, or permitting them to come in contact with some non-sterile article—such, for example, as a blanket which protects the patient—just prior to or during an operation, and proceeding with their work without thoroughly cleansing them again. If such errors in technique be committed by the operator him- self, he can scarcely expect his assistants and nurses to exercise proper precautions. I remember seeing a surgeon leave the operating- table, while performing an abdominal section, to pick up an unsterilized instrument which he wished to bend at a certain angle and employ in order better to expose the parts. In doing this he used as a support a table and a chair that happened to be near at hand, but which were unsterilized. After having bent the instrument to the desired shape, the surgeon proceeded to employ it immediately without making any attempt to sterilize either it or his hands. I have also seen a nurse, who was assisting with the handling of the 12 ASEPTIC SURGICAL TECHNIQUE. sponges at an abdominal section, take her hand- kerchief from her pocket, wipe her nose with it, and at once continue with her duty of passing the sponges to the assistant surgeon. On another occasion I saw a surgeon open an abdomen, and after himself exam- ining the structures of the pelvic cavity, invite two professional brethren who were looking on to do the same; and they were actually permitted to introduce their hands into the wound after having simply washed them for a minute or two with soap and water in a soiled basin. At another time an assistant, after draw- ing a ligature between his teeth, proceeded to thread the needle with it for the surgeon to use in the abdomi- “nal wound. Some surgeons have even been guilty of holding the scalpel between the teeth in the course of an operation. It would hardly be necessary to mention such glaring instances of faulty technique were it not for the fact that errors as bad as these have been observed in men who are considered leaders, and to whose lot it falls to instruct others in surgery. While the surgical judgment and skill of such men may be undoubted, the technique which they employ is dangerons and per- nicious. Even after we have become thoroughly im- bued with the importance of aseptic work, and have made the most careful preparations before our oper- ations, the technique will never be perfect unless we have schooled ourselves to provide against the unfore- seen dangers which are constantly turning up in the operating-room. Every operator of experience, no INFECTION. 1 matter how conscientious and careful, has met with fatal cases in his practice due to faulty methods, and has had inflammation with pus-formation at or near the site of the wound which he has made. He who is thoroughly conversant with the condi- tions which underlie suppuration in wounds and septic processes generally, knows only too well how many are the loop-holes for infection, and to him it seems really remarkable that such cases do not occur more frequently. It is not improbable, especially in condi- tions of lowered resistance where the cells and tissue fluids of the body do not exercise their normal germi- cidal power, or do so only in a feeble way, that infec- tion may occur, even though all possible precautions have been taken by the surgeon and his assistants. Experiments have shown that no method has yet been discovered by which the skin can be rendered abso- lutely sterile, and that the cutaneous glands contain, even after the most careful disinfection of the surface, micro-organisms which in a proper “soil” are capa- ble of giving rise to inflammation and suppuration. . Though it may be true, as has been contended by good men, that every wound made by the surgeon contains micro-organisms, we may assume that under ordinary circumstances the resisting powers of the patient will be sufficient to prevent their growth and development. Experience, however, has taught us that there are several kinds of bacteria which under certain conditions possess such virulence, that when introduced into the tissues even of a perfectly healthy 14 ASEPTIC SURGICAL TECHNIQUE. individual they are capable of setting up violent local or general infections. And it is only right that every surgeon shall do everything in his power to prevent the ingress of such bacteria. While admit- ting that an infection following an operation must, with our present knowledge, be sometimes attributed to a lowered systemic resistance and to no fault on the part of the operator or his assistants, it must be understood that this is a very rare occurrence, and that in nearly every septic case a rigid analysis of the technique employed will bring to light some sin of omission or of commission to account for it. I believe that a perfect technique can ultimately be attained by submitting every step to the test of bac- teriological examination, and the surgeon who works on these lines will, ceteris paribus, undoubtedly obtain the best results in his own operations, and, what is perhaps just as important, he will be able by his teach- ing and example to inculcate in others principles by the adoption of which much loss of life may be pre- vented. That some surgeons do not seem to pay much at- tention to a careful technique and yet obtain good results is no sound argument against the carrying out of thoroughly scientific procedures. As a matter of fact, a careful investigation of their results and those of their followers compared with those of aseptic surgeons and their students will, if a suffi- cient number of parallel cases be taken, certainly show the inferiority of the older methods. Statistics SEPSIS. 15 showing uniformly good results from operations in which no precautions were taken will usually be found to be based on too limited a number of cases to be of much value. The term sepsis, or septic infection, includes nearly all of the surgical infections, general or local, result- ing from bacterial invasion. The symptoms are due, as a rule, not so much to the direct effect of the bac- teria themselves as to the action of their chemical products. When the bacteria have gained entrance into the general circulation and have multiplied there (and several varieties are capable of doing this), we have a general blood-infection which often proves fatal. With or without extensive multiplication of the micro-organisms in the blood, the system may be overwhelmed with the bacterial poisons. This condi- tion is called acute septicemia. Localization of pyo- genic bacteria in the organs, especially when they have been transported there by infectious emboli, gives rise to multiple abscess-formation. This condi- tion is called pyemia. These terms are, of course, only relative, and it is customary to speak of infec- tions in which the two conditions are combined as cases of septico-pyemia. Under the head of local infections we at the present day group together all those so-called “ accidents” which befall wounds: suppuration, traumatic fever, hospital gangrene, wound-diphtheria, and erysipelas. All of these, though met with much less often than 16 ASEPTIC SURGICAL TECHNIQUE. of old, are still occasionally seen. The rarity of their occurrence is to be attributed to the improvement in operative technique and the less frequent infection of wounds. The phenomena appearing after the absorp- tion into the general circulation of the products re- sulting from the local growth of micro-organisms, especially putrefactive forms, have been included under the term sapremia or toxemia, but it is not possible to make any sharp distinction between sapremia and septicemia. The importance of recog- nizing clearly the distinction between a purely local infection and a general infection of the blood and organs with bacteria will be easily understood. In the former case the symptoms produced are in direct proportion to the amount of poison absorbed, and if this absorption has not been too great, they will all disappear with the subsidence of the local infection. In a general infection, on the other hand, fresh poi- son is being constantly produced by the bacteria dis- tributed everywhere through the body, so that local therapeutic measures can then be of no avail. General septicemia, or pyemia, may be set up by almost any of the micro-organisms which have pyo- genic properties,—i.e., which are capable of giving rise to local suppuration. The organisms most frequently met with in surgical experience are: the staphylococcus pyogenes aureus, the streptococcus pyogenes, and the bac- terium coli commune. Less frequently we have to deal with the staphylococcus epidermidis albus, the staphylococ- cus pyogenes albus, the staphylococcus pyogenes citreus, the PATHOGENIC ORGANISMS. 17 gonococcus of Neisser, the bacillus of green pus (bacillus pyocyaneus), the bacillus aérogenes capsulatus, and the micrococcus lanceolatus (diplococcus pneumonie). It will be well, perhaps, to describe briefly the prin- cipal micro-organisms which concern us in our work, and especially the pyogenic bacteria. The forms chiefly concerned in suppurative processes are cocci. Of these the staphylococcus, of which several varieties have been isolated, distinguished by differences both in their chromogenic properties and in their pathogenic power, has been found more frequently than any other associated with acute phlegmons. The staphylococcus pyogenes aureus (Ogston, Rosen- bach, et al.), or golden staphylococcus, is the most im- portant form for the surgeon, and is more common than any other. It is widely distributed in nature, its presence having been repeatedly demonstrated upon the skin of healthy persons, in the secretions of the mouth, beneath the finger-nails, in the air, especially in that of hospital wards, in the water, and elsewhere. It can thus be easily understood how readily it can come in contact with the field of operation. The cocci grow in grape-like bunches, but in the tissues are also seen in pairs or in groups of four. Plate L., Fig. 1. They stain well in the ordinary aniline dyes, and also by the method of Gram. The staphylococcus aureus grows well on’ all the culture media of the laboratory, and forms, especially when allowed to grow slowly with free access of air, large golden-yellow masses. 2 18 ASEPTIC SURGICAL TECHNIQUE. Its pathogenic power is variable, some varieties being much more virulent than others. Its pyogenic properties for human beings have been clearly proved by the experiments of Garré, who rubbed into the uninjured skin of his left forearm a pure culture of thisorganism. Four days afterwards a large carbuncle, which was surrounded by isolated furuncles, appeared at the site of the inoculation. The inflammation thus established ran the usual course, and it was only after several weeks that the skin healed over completely. Seventeen scars remained as a lasting proof of the success of the experiment. When cultures of this coccus are injected into the vein of a rabbit’s ear, the animal dies after a certain period of time (which varies according to the viru- lence of the particular culture used), with symptoms of acute septicemia, and at the autopsy necroses or small abscesses are found in the various organs. In human beings this organism has heen isolated from suppurating foci of all kinds and in all situations. It is the most frequent cause of superficial and deep abscesses as well as of acute osteomyelitis, and has often been recognized as the infectious agent in acute ulcerative endocarditis and general septicemia follow- ing operations or childbirth. The staphylococcus pyogenes albus, while resembling the aureus in form, can be distinguished from it in that it grows as a white coating on the culture media, and moreover is possessed of less virulence. It has in some instances been found as the only micro-organism