CHAPTER V Every ambitious man has been impressed by certain lessons (Part 4)

that every man would die as the result of every pin-prick were it not for the resistance to bacteria which was offered by his body cells. It was noted 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 was clear — that the nearer we could bring a surgical operation to pin-prick character, the better the chances of that patient for meeting infection with his own internal resources. Most important of all was the gradually accumulated testimony from my own cases of intra-abdominal infection in which products of bacterial action were purposely left in the peritoneal cavity at times when their removal would have added to the degree of shock. At one time I arrived at the point of closing the abdomen without drainage after operations for appendicitis and pyosalpinx with abscess, and even turned the canal of a psoas abscess into the peritonea] cavity, believing that the patient would then be less exposed to the dangers of infection from the air. This was found to be running the idea past its limitations, although no patient was I injured. Calmly presented scientific papers by other authors I bearing upon the subject were being overlooked. For that I reason 1 continued to employ a style in presentation which was harmful to me personally, but more effective for throwing a J TO-MORROW'S TOPICS 267 diamond hitch about the loose ends of the new load for a profession that was already overburdened and restive. Surgeons of the entire world were at this time reaching extreme limits of operative technic belonging to the third era. They were exhausting the reserve supplies of energj- of their patients through dangerously conscientious observation of rules for removing products of infection. My statistics seemed only to irritate colleagues and I apparently stood practically alone for a long time against the sweep of the current of the third era, which had the tremendous momentum and velocity belonging to enthusiasm based upon scientific conviction. I was trying to make potential energy of the fourth era transform the tremendous kinetic energy of the third era. Statistics olTered in evidence to show that the third era was passing its pivotal point and meeting the law of diminishing returns seemed like trying to stop a river by tossing in a stone. Distinguished surgeons visiting New York came less often than formerly to see me, and when dining with other surgeons presumably asked the familiar question — "Between you and me, what do you think of him?" It is this "between you and me" question that leads to the inhibiting of progress as well as to the comfortable and companionable commission of crime. The effect upon my practice was dis- astrous. Hardly a week passed that I did not learn of some case that had been turned away from me to some other surgeon, and were it not for a very thrifty somebody in the home, the question of means of support for my family would have been a serious one indeed. One day at New Orleans my dear old friend, M. H. R.. of Boston, said: "Let us go out for a stroll. I want to talk with you." As we walked under the beautiful live oaks together, his remarks 1 substance as follows: "When a man has done as much for our profession a :s were in M on as you ^M 268 TO-MORROW'S TOPICS have done I hate to see him go to smash along a wrong road. You are certainly all wrong in this matter, and your teaching is dangerous. You do not realize the volume of work that is being done in this country, and the adoption of a method of surgical procedure from a teacher may mean the actual saving or the actual losing of very many lives every day. A good many men look upon your statistics as imtruthful, or at least arranged favorably. I do not look at them in that way myself. My idea is that either you classify abdominal infec- tions differently from the rest of us, or your reports cover the sort of cases that the rest of us save, — or else, what is likely enough, you have had one of those remarkable runs of luck which will sometimes come to any man and lead him all astray for awhile. None of the men in New York seem to believe in you in this matter excepting W. T. B. He thinks your idea is right, but says that it makes his blood nm cold and he does not dare to follow in your lead. I told him pre- cisely what I have just told you and that he shows his cus- tomary surgical judgment and discretion in not following your lead.' My reply was, "Let me run up to Boston and care for three or four of your cases of appendicitis with advancing peritonitis. Just send me a telegram at any time and I will take the first train." "There!'' he said, "Just what I thought! You can't mean what we mean, in this class of cases at least, or you would not have a patient wait about seven hours at the best for your arrival from New York." As a matter of fact, on the spur of the moment I had misspoken. Such cases really could not be kept waiting. Boston was one of the last cities to adopt any of the prin- ciples belonging to the fourth era, at least in relation to ab- dominal infections. The reason for this was because of the high degree of learning and skill which had been developed in TO-MORROW'S TOPICS 269 that city when the principles of the third era were throwing a great new light over the entire field of surgery. As a general proposition we may say — The better the surgeon the more difficult it is for him to put aside a fine structure of elaborate knowledge that has been carefully built out of his best con- science and intelligence and approved of by tradition. One of my German friends, a man of the highest standing in scien- tific surgical circles, said : "I do not care what your statistics are; we must not follow your idea. We must stick to principles." In the very inner circles there is always someone who knows all about some one's else work. Furthermore, there are always outsiders who wish to know, and who make inquiry in these inner circles. The halting of progress and the suppression of an advocate of new principles is temporary only, and it represents a healthy normal movement. It means that no man is to be allowed to advance ideas rapidly until busy men have had time and opportunity to look the subject over in their own way. In the Medical News for July 2nd, 1904, Dr. Hotchkiss stated that in one of the hospitals with which he was connected emergency cases made up a large part of the work. The mortality rate in appendicitis previous to 1898 was, in that hospital, 31 per cent., under the accepted methods of the third era of surgery. After adopting for trial the methods of the fourth era of surgery, which he had formerly held to be unsafe or dangerous, Hotchkiss had a run of 72 appendicitis cases without a single death, although 26 cases of the series were of gangrenous appendicitis with or without perforation, and 15 cases of gangrenous appendi- citis were complicated by a spreading peritonitis. Stop and think about that for a moment. Through the influence of steadily keeping up pressure, like the man at the dock with his back against a loaded canal boat, I gradually felt the 270 TO-MORROW'S TOPICS principles of the fourth era swinging out into free sailing room. First there was a report that someone in Paris was following up the idea. Then came favorable news from Bonn, — and from Australia. Surgeons in various parts of the world were listening. In Qiicago, where one famous surgeon had reported 14 consecutive deaths in 14 cases of appendicitis with spreading peritonitis managed according to the principles of the third era, Ochsner and Murphy intro- duced such great improvements relating to ideas of the fourth era that the death-rate was brought below 5 per cent, in that same class of cases. A laj-man would probably find it difficult to comprehend the nature of a struggle over principles in surgery. He would naturally ask : "Why don't surgeons settle such questions promptly if it means, as it does mean, the saving or losing of hundreds of lives every week?" If the layman were a lawyer we might answer him with the story of a good old lady who did not understand why expensive legal talent was arrayed on both sides of the question if a certain socially prominent woman had committed theft. The old lady decided the question promptly in her own mind. Said she: "If Mrs. Blank says that she did commit theft, they can punish her without the aid of lawyers. If she says that she did not commit theft, they can try her case with lawyers. In my opinion, if she does not say that she did not commit theft, it is clear that she did." One particular feature in connection with my work relating to the fourth era of surgery aroused a great deal of adverse criticism. During the most refined part of the pathologic era surgeons employed rubber gloves in the idea of lessening the number of bacteria which might be carried into a wound upon their hands. Rubber gloves, however, had the effect of lessening that trained sense of touch which is so important to the surgeon, and operators wearing gloves were not prepared J TO-MORROW'S TOPICS 271 to do as dexterous work in some fields of surgery, particularly abdominal surgery where the sense of touch is more important than the sense of sight. I made a demand upon the profession to give attention to this point, and stated that we could not fully carry out the principles of the fourth or physiologic era if we were still to use rubber gloves in abdominal surgery, because such long incisions were required in order to allow one to work freely when guided by the sense of sight. The nimiber of bacteria that would be carried into a wound by the bare hands of a careful surgeon would presumably be less than the number of bacteria falling into a large wound from the air while the surgeon was at work. Rubber gloves had come to form such a routine part in the work of the third era that the profession, as a rule, objected very seriously to the firm stand which I took against the indiscriminate use of rubber gloves. Another feature which caused a great deal of adverse criticism was the bringing forward of the new and old principle relating to the advantages of rapid operating. The painfully detained technic developed by surgeons during the third era required a great deal of time at the patient's expense. Any one who neglected to follow all these details, preferring to give the patient advantages of a rapidly performed opera- tion, was called a careless surgeon because he did not stop to give an extreme degree of care to each step. "Careful surgery" sometimes led to having a lifeless patient in cases in which quick work, neglect of details, and "careless surgery" would have left the patient with plenty of energy for over- coming the effects of neglected details. Many years must pass, even in these times of rapid change, before the principles of the fourth era will be carefully grasped. I recently watched an operator who cut out a dark- colored, thickened, lymph-covered omentvmi in an appendicitis 272 TO-MORROW'S TOPICS operation. It was really loaded with protective material bi "looked bad." He then proceeded to devote nearly twen^f minutes to getting out purulent material, almost all of whii might have been left in the abdominal cavity without harm. A very long incision was employed, and more than an houfi of time expended upon an operation which might have been completed with ease in ten or fifteen minutes through a short] incision, according to the principles of the fourth era ofi surgery. Further than that the patient was left with a weak point which would favor the development of a post-operative ventral hernia, — an altogether unnecessary defect in this par- ticular case. Principles of the third era are still employed harmfully in the dressing of open wounds, (l) Germicides like peroxid of hydrogen, bichlorid of mercury, or carbolic acid are employed for cleansing purposes. They destroy new repair cells. Saline solution would be employed instead in accord- ance with fourth era principles. (2) The wiping of a wound ever so gently injures new repair cells. The fourth era surgeon would prefer to leave purulent material in place if it could not be readily flushed out with saline solution — and no wiping. (3) Absorbent dressings when placed in contact with wound surfaces injure new repair cells. The fourth era surgeon places a protective medium like silver foil or Cargile membrane between the wound and the absorbent dressing. Procedures which are right now in daily employment as virtues according to the third era idea, are vices from the fourth era viewpoint. A great deal of harm has been done in surgery by the en- ployment of germicides when antiseptics which are not germi- cides would have sufficed. We must remember that bacteria and body cells both consist of protoplasm, and that protoplasm of body cells is injured by any germicide of sufficient power I TO-MORROWS TOPICS 273 for injuring the protoplasm of bacteria. Bacteria depend upon their own vital energy, while repair cells depend in a way upon a greater store of energy from the body cells which give them birth. This gives the patient a natural advantage. Were it not for this fact, surgeons would have more quickly come to realize that a germicide was simultaneously destructive to repair cells and to bacteria. There are many antiseptics which inhibit the development of bacteria without injuring them severely, and at the same time do not injure repair cells very much; but even these antiseptics are often less desirable than a simple saline solution, which is isotonic with blood serum and which gives body cells and bacteria an even fighting chance. Under these circumstances the body cells often win better than when they are aided by allies of antiseptics which complicate the military program. Even at the present date in the history of progress of surgery the majority of surgeons in all countries have not as yet emerged from the dark ages this matter. Bichlorid of mercury, carbolic acid, and peroxid of hydrogen, while immensely valuable in a few situ- ations, are, on the whole, perhaps more harmful than valuable when applied in wound treatment by the laity, by nurses, by general practitioners, or by surgeons who follow principles of the third era of surgery too indiscriminately. For household purposes by the laity there is no handier antiseptic than plain borax water, although some of the powerful antiseptics which are not germicides would be preferable if the public could only get to know about them. In addition to the idea included in tlie principles of the fourth era of surgery, of causing the least possible degree of shock through operative procedure (thus avoiding undue liberation of energy which is stored up in the cells of brain and nerves, and necessary for conducting repair), the psychology of the patient in advance of the operation was I TO-MORROW'S TOPICS 275 completing an operation without jeopardizing any of the patient's interests was employed. Viscera were left undis- turbed as much as possible and not subjected to the effects of my curiosity. Crile very soon afterward amplified this general idea on a basis of good philosophy, and introduced refinements along the same line. {Gushing first introduced the idea of blocking nerve sensation in the course of an opera- tion. He applied the process to large nerve trunks, while Crile went a step farther by applying it to small and more active nociceptor nerves of the skin and superficial tissues. Corning was the first to block the spinal cord. These are all American investigators.) Crile accomplished with morphine and scopola- min in advance of operation what I had attempted with a bit of applied psychology. His two drugs have the effect of breaking up the associative faculty, including the group of fear thoughts which a patient has usually gotten together in advance of operation. Crile showed further, that ether and chloroform take into solution not only lipoids of ductless glands, but also those of brain cells, and that anesthesia with chloroform or ether is partly due to interference with conduction of nerve impulse to the brain by the obstruction caused through the presence of disorganized cell contents. Crile showed still further that by the injection of local anesthetics along the lines of incision, sensory-nerve impulse which caused waste of energy from brain cells was lessened. He advocated the employment of nitrous oxid and oxygen which did not take lipoids into solution, and which caused less disturbance in other ways. It has been a great satisfaction to observe the advantages to the patient given by the refinements introduced by others at a time when my own work along the same line represented the beginnings of a systematic method for con- serving the energ)' of the patient and allowing him to turn it over to the account of repair. 276 TO-MORROW'S TOPICS ^^H The principles of the fourth era of surgery as applied W. emergency complications of typhoid fever and of ulcer of the stomach are not as yet approved of by the medical profession. When there is typhoid perforation of the bowel, a patient's