How Modern Surgeons Conquer Fatal Germs (Jan, 1933)
How Modern Surgeons Conquer Fatal Germs
By Frederic Damrau, M.D.
A SMALL item recently appeared in the newspapers. It reported a new ruling of the American College of Surgeons. In the future, all surgical thread must be tested thirteen days instead of six to insure its freedom from germs. That tiny item was buried in the back pages of the papers. Few people read it. Yet, behind it lies one of the most thrilling chapters in the whole dramatic story of death-fighting by surgery.
Less than seventy years ago, such a simple operation as the amputation of a finger was a life and death matter. In one famous European hospital, eleven out of seventeen amputations resulted in death from blood poison. Germs of infection were unsuspected. Sterilization, as we know it today, was unknown. Antiseptics were undreamed of. Doctors knew little about infection and were helpless before it. It was not until after the Civil War, that antiseptics first appeared and revolutionized the science of surgery.
Before then, only a few kinds of operations were ever attempted. The odds against the patient were heavy and the work of the most skillful surgeon was often undone by swarming germs. Today, with this menace of microbes in the operating room conquered, several thousand kinds of operations are commonly performed and almost daily new feats, that read like astounding fiction, are added to the case-books of famous surgeons.
Witness, for example, this instance coming from Chicago, Ill.
A fifty-six-year-old man was suffering from the dangerous condition known as anuerism of the aorta. This means that the main artery, through which all the blood of the body flows, had become flabby and distended. With every pounding heartbeat, the weakened walls bulged outward. At any moment, they might burst and death result. It was as though the man walked about with a cocked and loaded gun pointed at his heart.
On the operating table, Dr. Raymond W. McNealy, noted surgeon, performed a daring experiment that saved his life. Cutting a long incision near the heart, he reached the aorta. Then, around this artery he wrapped seventy feet of special gold and platinum wire, about the same diameter as number twenty-nine piano wire, strengthening the walls and holding them in place. Today, with blood pumped to his body through this wire artery, the man is in excellent health!
Some years ago, I witnessed another marvelous operation for the same mysterious disease. In this case, the aorta had dilated into a large bag with the walls stretched almost to the breaking point. In the operating room, I saw the surgeon push a hollow, insulated needle into this bag and then pass thirty feet of fine gold-platinum wire inside.
This wire, unwinding from a spool of approximately the same diameter as the distended aorta, curved around and around within the walls of the cavity. As soon as it was in place, the surgeon attached the outside wire to the positive pole of a battery and placed an electrode from the
negative pole under the patient’s back. For three-quarters of an hour, the current passed through the wire in the artery. Then, the surgeon removed the electrode and snipped off the wire, leaving the thirty feet within the aorta. The effect of the current passing through the bloodstream had been to form clots around the wires inside the walls. These clots later hardened into permanent form, resembling scar tissue. This added to the thickness and strength of the walls, thus prolonging the life of the ailing man.
Whenever wires are used in operating rooms, they are always sterilized by boiling them in water or by passing them through naked flames. Nothing enters the swinging doors of such a chamber without a searching inspection. Every bandage, every instrument, every gown is carefully sterilized. By rigorous regulations and unceasing vigilance, the patient is protected from infection in the modern hospital.
Contrast with this the conditions eighty years ago. Common sponges were used to wash out wounds and the same sponge was used on several patients, the physician merely squeezing it out in water between times. Instead of white robes, surgeons wore “operating coats,” the dirtier the better, as soiled and bloodstained garments were thought to be an indication of the wearer’s wide experience. The nearest approach to protection against germs was a small canopy of linen sometimes erected over a wound to keep out dust.
A seemingly unimportant event, occurring about the time Grant met Lee at Appomattox, began the transformation that changed such conditions into those of the present. A young surgeon in Edinburgh, Scotland, read a pamphlet entitled: “The Decomposition of Inorganic Fluids.” The pamphlet was by Louis Pasteur. The young surgeon was Joseph Lister, now world famous.
For months, Lister had been spending his spare time peering through microscopes at the feet of frogs and the wings of bats. He was trying to find out exactly what happens in the thin sheets of membrane when inflammation sets in. For eleven years, he had been searching for a method of making wounds heal perfectly. Then, in a flash, Pasteur’s pamphlet, reporting the discovery that bacteria cause decomposition, suggested the solution. Invisible microbes cause infections! This “germ theory of infection” forms one of the really great discoveries of all time.
Lister’s first step in combating microbes was the development of a “carbolic acid putty” for sterilizing wounds.
Later, he designed a throe-legged pump with a long handle, worked by an assistant, which shot clouds of carbolic acid spray over both surgeon and patient during an operation. The spray affected the stomach and choked up the lungs. It numbed and whitened the hands of the surgeon and got in the eyes of the patient. But, in its crude way, it killed germs and saved lives. This wheezing pump of Lister’s, dubbed “The Donkey Engine,” started surgery on its road to the wonders of today’s operating rooms.
His was the “antiseptic method.” It concentrated on killing the germs in the wound during the operation. Modern hospital technique has taken another step forward. It employs the “aseptic method.” This concentrates on preventing germs from ever reaching the operating table.
The infinite pains required to make it a success can best be illustrated by taking you behind the scenes and letting you watch, step by step, the precautions taken before, during, and after an operation.
Incidentally, this backstage glimpse will answer some of the common questions people ask me, such as: Why do surgeons wear masks over their faces? What is the longest time an operation ever takes? What would happen if a surgeon died in the middle of an operation? Is everything quiet in the operating room or does conversation go on? The work of protecting the patient from infection begins the night before the operation. The spot where the incision is to be made is washed off with hot water and tincture of green soap. Then all hair is carefully shaved away, the spot is again washed with alcohol, and finally covered with a sterile towel. The next morning, alcohol is again applied, then ether, to dry the skin, and lastly iodine, or in cases where the skin is tender and will be burned by iodine, a combination of picric acid and alcohol.
Clad in a sleeveless flannel chest protector, or “ether jacket,” and long woollen stockings, the patient is wheeled into the chamber where the anesthetic is administered. This is usually a small room connecting with the main operating room. All jewelry has been removed. Even wedding rings cannot be worn into the operating room. When patients object to this rule, the rings are sometimes sterilized and secured to their wrists.
In an adjoining room, the surgical team is getting scrubbed up for the operation. Hands and arms, to a height of two inches above the elbows, are washed for ten minutes with hot water and tincture of green soap. Washstands are equipped with foot or knee levers for regulating the . flow of water so the hands never touch faucets. Sterilized white gowns of lawn or muslin are then slipped on and caps are pulled into place covering all the hair. Masks of gauze, five or six layers thick, cover the mouth and nose to prevent the breathing of a nurse or surgeon from carrying germs into a wound. Every member of the team must be in good health and free from colds.
Extra-strong sterilized rubber gloves cover the hands. They have been soaked in a five percent carbolic acid solution for two hours and then powdered. Each glove is blown up and tested for leaks before it is used. Even a pin-prick cannot be disregarded. Germs from the hands might work their way through it into the wound, for, no matter how long they are scrubbed, hands never become surgically clean. Again, virulent pus from a ruptured appendix or other infection might find its way into the faulty glove and endanger the life of the surgeon.
IT REMEMBER one dramatic moment of the sort in an eastern operating room. The famous surgeon, Algernon Bristow, was performing an emergency operation on a patient with a ruptured appendix. As he removed his scalpel, dripping with pus, the razor-sharp edge flicked across a fingertip, slitting the glove and the skin beneath. The operation was at a critical point. He dare not stop even long enough to change his glove, for the primal law of the operating room is:
The Patient Comes First. He realized his danger, but we saw him tighten his lips and go on. By the time he had finished his work and sterilized the cut, the germs had entered his bloodstream. That was the last operation he ever performed. A week later he was dead.
Nothing in the operating room is touched by any one except those who are scrubbed up, that is, completely sterilized. An unbroken aseptic chain must be maintained in handling every object. If an instrument drops to the floor during an operation, it must be reboiled the full twenty minutes, except in extreme emergencies when it is sterilized by passing it several times through the flame of burning alcohol. Between operations, and often between two parts of an operation on the same person, everything in the room is
cither changed or sterilized. Gowns, gloves, instruments, and utensils are all shifted as an added precaution against infection.
The members of a surgical team are drilled like soldiers. Wartime discipline rules in the operating room. No one speaks except the surgeon and the anesthetic expert who reports on the breathing and pulse of the patient. Every operation is a race against time, some lasting more than three hours, so there must be no confusion, no waste motion. Each member of the team has a definite duty to perform. One nurse is responsible for the proper placing of the patient on the operating table and the adjustment of the lights over it. Another does nothing but remove lids from basins, place buckets and fill pitchers. The suture nurse hands instruments and sewing materials to the surgeon, always holding in reserve a duplicate of the instrument he is using so in an emergency, it can be replaced without an instant’s delay. Another member of the team is detailed to check the sponge count, making sure none of the gauze pieces are sewed up inside the wound.
A fifth nurse presides over the autoclave, the polished metal cylinder in which gauze, bandages, and towels are sterilized by steam under pressure. Increasing the pressure in the chamber raises the boiling point of the water. At twenty pounds pressure, for instance, water, which ordinarily boils at 212 degrees F., requires 260 degrees, thus increasing the heat to which the microbes are subjected.
The work of the autoclave nurse is of key importance. I recall the terror that seized us, some years ago, when three successive cases leaving our operating room developed infection. We appealed to a bacteriologist. Like a detective, he traced the microbes to their source. Gauze dressings, applied to the wound after the operation, had not been sterile. A nurse in charge of the autoclave had-hurried them through the sterilizing process, saving a few minutes at tremendous expense.
NOWADAYS, to insure every bandage is completely sterile, changeable ink is placed in the chamber. It alters its color only when it has been left in the autoclave long enough to kill all possible germs of infection. Diack controls, small glass tubes containing a substance which also changes color with adequate sterilization, are similarly used. In addition, cultures of live germs are sterilized in the autoclave once a month and then examined in the laboratory to make sure all microbes are being killed.
Overseeing the work of the team is a head nurse who gives the final O. K. to the sponge count and is prepared to assist at any post during an operation. One of her duties is wiping the face and brow of the surgeon. A single bead of perspiration falling into an open wound would carry germs inside and undo all the precautions that have been taken. The temperature in operating rooms is automatically kept at between seventy-eight and eighty degrees F. To absorb perspiration and protect patients, many surgeons place pads of folded gauze over their foreheads under their sterilized caps.
Standing beside the surgeon, during every serious operation, is a second surgeon, ready to assist him or take up the work at any point in an emergency.
Sometimes, such emergencies come like flashes of lightning.
In Birmingham, Ala., a few months ago, Dr. T. H. Williams was in the midst of a delicate abdominal operation when he clutched his left side, gasped, “Doctor, take care of my patient!,” and dropped dead of a heart attack. In spite of his shaken nerves, his assistant, Dr. R. M. Coston, finished the operation successfully.
Again, in Kansas City, Mo., recently, a surgeon was finishing a night operation for appendicitis when he himself was stricken with an acute attack. He collapsed beside the operating table and his assistant had to finish the work and then perform an emergency operation to save the life of his colleague.
Most dramatic of all was an occurrence, not long ago, in Berlin, Germany. The famous specialist, Dr. H. Sauerbruch, was operating on a twenty-two-year-old girl who had developed heart trouble after an attack of influenza.
IN THE right side of her chest, the X-ray showed a large swelling. Shortly before, the surgeon had found a similar swelling in a man’s chest. It proved to be a blood blister which he had punctured and successfully eliminated. Planning a similar operation on the young woman, he made his incision and cautiously jabbed his needle into the swelling. Nothing happened. A second time he jabbed, this time with greater force. Instantly, a thick bloodstream poured out, rapidly widening the opening. Instead of a blister, the swelling was a blood-pouch of the heart itself!
Frantically, Sauerbruch sought to stop the rush of blood. Plugging the opening with his finger, he could feel the lifestream within the right ventricle virtually boil and bubble. In the wink of an eye, the operation had become a two-man job, impossible to complete without the aid of his assistant. While he closed the hole as best he could, the assistant placed the stitches, Sauerbruch gradually removing his finger as the opening drew together until it was completely closed.
A curious climax to the case is the fact that the patient not only recovered but is in vastly better health due to the elimination of the blood pouch. Had the surgeon known what the apparent blister really was, he would never have dared operate. His mistake in diagnosis cured the girl of heart trouble!
When an operation is over, the fight against infection continues as actively as ever. Sterile bandages keep germs from reaching the wound and, when pus is present, drainage tubes carry it away. Until the Battle of Turin, in the Sixteenth Century, boiling oil used to be poured into wounds to hasten healing. At this battle, the oil ran out and surgeons discovered to their amazement that wounds which were not treated in this way healed quicker than those that were. Lister, in one of his later experiments, used to place bunches of horsehairs, treated with carbolic acid, in wounds, removing the hairs a few at a time as the opening closed in healing.
ONE of the most important medical discoveries in recent years is the use of surgical maggots in curing chronic infections. During the World War, two soldiers who had been injured by shellfire lay in a thicket for seven days before they were discovered and brought to the base hospital. When Dr. William S. Baer, famous Johns Hopkins surgeon, examined their wounds, he found a remarkable thing. The larvae of blow-flies in them had kept the wounds clean, consuming dead tissue, preventing infection and setting up a healing action.
After the war, Dr. Baer carried on a series of experiments with carefully-bred sterilized maggots. With them, he achieved remarkable success in treating almost incurable bone infections, compound fractures of the thigh, and tuberculosis of the hip. Out of 200 cases treated at the time of his death in 1931, he had achieved ninety-five percent cures among children and eighty-five percent among adults. Since then, his method of treatment has been widely adopted.
Not only is it important to give careful attention to the outside of a wound to prevent infection, but also the circulation of the blood to it, purifying it from the inside, must be unimpaired or gangrene is likely to set in. At the famous Mayo Clinic, at Rochester, Minn., not long ago, a remarkable bit of surgery saved a patient from this dread form of infection.
A HOTEL guest awoke in the middle of the night with a stabbing pain just above his left ankle. It felt as though the bone were dry and about to break. His foot was numb and black and brown blotches were beginning to appear on his leg. Thoroughly frightened, he called the hotel physician, who diagnosed the mysterious trouble as a blood-clot in the main artery of the left leg. Unless the clot could be removed, allowing the blood to flow freely to the leg again, gangrene would putrify the flesh and amputation would be necessary.
The suffering man was rushed to the Mayo Clinic. Here, one of the famous surgeons of the staff made a tiny slit, only an inch long, at the point where the obstruction was located. Clamping the artery to prevent bleeding, he cautiously pushed his scalpel blade through the wall and with deft fingers removed two large clots. When the artery had been securely sewed up with surgical silk, he removed the clamp. Once again, blood flowed through the limb. Immediately its condition improved and in a short time the patient was out of bed.
For permanent stitches in arteries and intestines, sterilized silk is used. In places where tissues will grow together, catgut, which dissolves and is absorbed by the body, is employed. These catgut threads, or sutures, are timed to dissolve in eight days, ten days, twenty days, and forty days, the surgeon choosing the type that will hold the tissues together just long enough for them to knit. The sutures withstanding the action of the chemicals of the body longest are ones which have been tanned by the process that produces chrome leather.
IN SURGICAL sewing, it is important to injure as little of the tissue as possible. Instead of being threaded through an eye, the catgut is attached directly to the needle, one end slipping into its hollow rear and being crimped in place. Thus the hole made in the tissues in sewing is the diameter of the thread instead of twice that, as would be the case if an eve needle were used. The sutures come, with the needles attached, in hermetically-sealed glass tubes, some straight and some shaped like little canes. These tubes are broken and the sutures extracted as they are needed during the operation. When the work is done, the needles are clipped off and thrown away.
All surgical catgut comes from the intestines of sheep with the exception of a special, super-strong variety used in tying bones together. This is obtained from the tail tendons of kangaroos. In small skin wounds, where there is little tension, horsehair is sometimes employed as surgical thread. Clips are now widely used in place of sutures in holding together many kinds of external wounds.
One of the queerest cases I remember in which a makeshift suture saved a life, occurred, a few years ago, five hundred miles at sea. A young doctor had shipped at the last minute as surgeon on a dilapidated, cut-rate steamer, carrying 900 passengers. The ship was past Sandy Hook, heading for England, when he examined his equipment. He found there was no operating room, no sterilizing equipment, and only a few out-of-date surgical instruments on board. Then, five days out, one of the passengers collapsed with an acute attack of appendicitis!
The captain informed the surgeon he could operate wherever he pleased. He chose the smoking room and had it cleared. Draping sheets around two card tables in one corner he formed a booth which he disinfected with formalin lamps.
AN OLD Russian apothecary on board ad- ministered the anesthetic. Just as the patient was going under, the doctor discovered all the sutures were rotten and would break at the slightest touch! Was there a violin on board? The chief officer dashed upstairs and returned with the skipper’s fiddle. Tearing off the E-string and sterilizing it, the surgeon used it for catgut to sew up the wound at the end of a ninety-minute operation which resulted, miraculously enough, in the patient’s complete recovery.
A HUNDRED years ago, a patient needed superhuman courage to undergo an operation for he was conscious while the surgeon worked and had to bear the pain as best he could. That is no longer true. The discovery and use of anesthetics is a thrilling chapter in the story of modern surgery. Next month Dr. Damrau will tell what an anesthetic is, how it is administered, and the effect it has on the patient. Also he will describe amazing operations performed with its help. See Popular Science Monthly for February.
First to Use Antiseptics
Seventy years ago, even trifling operations were highly dangerous. It was not until Joseph Lister, noted English surgeon, developed his germ theory of infection that surgery came into its own. As a result of his crude efforts, sterilization now keeps all germs out of the modern operating rooms.