ASEPTIC SURGERY IN THE HOSPITALS OF PARIS IN 1892. BY L ROBERT REYBURN, M.D., WASHINGTON, D. C. FROM THE MEDICAL NEW?, December 17, 1892. [Reprinted from The Medical News, December 17, 1892.] ASEPTIC SURGERY IN THE HOSPITALS OF PARIS IN 1892. To the Editor of The Medical News, Sir : During the past six years I have made three visits to Great Britain and the Continent of Europe, viz., in 1886, 1890, and 1892, and I have studied with much care and interest the progress and development of asep- tic surgery in these countries. During the summer of 1892 I paid special attention to what I saw of the surgery of London, Berlin, and Paris. The present letter will treat only of aseptic surgery as I saw it in the hospitals of Paris in 1892. The history of the influence of bacteriologic studies in the development of aseptic surgery is one of the most interesting and important of the modern records in the science of medicine. The wildest dreams of our imagination could never have foretold the momentous consequences that would result from the discovery and investigations of bacteria and other minute microorgan- isms. It is a striking illustration of the fact that we often do not and cannot appreciate how far-reaching and im- portant a scientific discovery may be, even when at the time it seems to have no practical use or benefit. To the great Prof. Pasteur's labors, chiefly, we owe the foundation upon which antiseptic and aseptic surgery have been built. He demonstrated that the processes of fermentation and putrefaction are entirely due to the presence and action of these microscopic germs, and if these are absent such changes will never take place. This was followed by the labors of Prof. Tyndall, of England, who conclusively proved that if we would 2 completely exclude the living germs or bacteria of the air from infusions of animal or vegetable matter, they could be kept indefinitely. Infusions, such as beef-tea, mutton-broth or chicken-broth, and infusions of hay and other vegetable matters, may be kept for years, if, after boiling to sterilize or kill the living germs contained in them, they are hermetically sealed to exclude the air which contains the germs. He also found that if the mouths of the vessels containing these infusions are plugged up with aseptic cotton, to filter out the germs as the air passed in and out, these infusions could be pre- served indefinitely. To Prof. Lister we owe the grand idea of excluding the bacteria and other germs from wounds, thus creating the then new science of antiseptic surgery. It is per- fectly true that aseptic surgery, as now practised in this country and in Europe, is very different from and far superior to the cumbrous procedures and dressings de- vised and practised by the father of antiseptic surgery ; nevertheless, we must never forget that to Prof. Lister we owe the practical development of the principles un- derlying what we now know to be the true science of aseptic surgery. The carbolic spray, once universally applied, has been almost entirely abandoned, and during my recent visit to Europe I never saw it once used. The many layers of protective gauze, mackintosh, etc., are now replaced by a simple layer of iodoform-gauze, with an abundant layer of aseptic cotton firmly retained by bandages. Another remarkable change is in the growing disbelief in the efficacy of the ordinary antiseptic solutions when used as germicides. A solution of carbolic acid has been shown to be a very weak germicide, and the same may be said of a solution of boric acid and of the other solutions used commonly for this purpose. Mercuric chloride has until the present time been our sheet- anchor as a germicide. As we lost our faith in one 3 germicide after another, we thought we could rely on that. Yet the iconoclasts are busy in their work of tear- ing down all idols in medicine, and now they have not left us this one. Recent investigations carried on at Johns Hopkins University (published in the Johns Hopkins Hospital Bulletin of April, 1891, p. 50) and at the Uni- versity of Michigan (published in The Medical News of October 1 and 8, 1892) have shown that solutions of mercuric chloride when used as a germicide are often inert, and still oftener actually injurious to the tissues when applied during surgical operations. The great surgeon, Lawson Tait, believes in no germicide except recently boiled water, and observation teaches us that the consensus of opinion of the great masters of sur- gery is fast settling upon the conviction that there are practically only two methods of keeping wounds aseptic. One is to keep wounds made during surgical operations as dry as possible, and the other is to use only recently boiled water in contact with them. Every instrument and surgical appliance must be sterilized either by boiling in water containing soda, or by being exposed to dry heat above the temperature of boiling water for at least one- half hour. To this, of course, must be added absolute cleanliness of the operator, the assistants, nurses, and of all the appliances used in surgical operations-the operating- room and all the surroundings, of course, included. The present paper will, however, be confined to aseptic sur- gery as I saw it in three of the hospitals in Paris, namely, in the Hotel Dieu, Hopital Tenon, and the Hopital Bichat. The Hotel Dieu, the oldest hospital in Paris, was originally situated on the south bank of the Seine, and the old building is said to have been founded by Clovis II in the year 660. The present building is located on the north side of the Place Notre Dame, and was rebuilt in the years 1868-1878. Like many of the European hospitals, it is quadrangular in shape, with a 4 courtyard in the center, and accommodates about eight hundred and fifty patients. The hospital is clean and well ventilated. Contagious diseases are not usually admitted, but are sent to special hospitals. Some cases of cholerine (so called) were in the hospital, and I saw in an English paper a statement that one hundred cases of cholerine (or cholera) had been admitted to the Hotel Dieu the day I left Paris. I am unable to state of my own knowledge whether any of the cases of cholerine were really Asiatic cholera or not, but I saw in the morgue of the Hotel Dieu several bodies of patients who had died of this disease. The Hotel Dieu has a very large number of patients attending daily for the purpose of being operated upon and prescribed for. These clinics are truly immense. The most famous surgeons of Paris are numbered among the hospital staff. Those on service at the present time are Lancereaux, Tillant, Verneuil, Panas, Proust, Cornil, Brequoy, and Labbe. Dr. Henri Hartman, whom I met for the first time on August 25, 1892, is also acting as one of the surgeons of the hospital of Hotel Dieu, and to him I am indebted for many courtesies during my stay in Paris. He invited me to meet him at the Hopital Tenon on the following day, August 26, 1892. The Hopital Tenon is a new hospital containing about one thousand beds, and in point of cleanliness and ventilation was in an admirable condition. I examined with great interest the lying-in wards, and found the most perfect arrangements for asepsis in them. From sixty to eighty confinements take place there per month, and since the introduction of strict asepsis, the mortality has been almost nominal. The management of all the Paris hospitals is entirely vested in a Council of Administration, who make the appointments of surgeons and directors of the hospitals. All the subordinate positions, such as internes (or what we call resident physicians or students), are filled by 5 competitive examinations. This same system is applied to the promotion of nurses and other employes of the hospital. At the last concours, out of 627 candidates for the position of interne, only 56 appointments were made. The course of study for a student of medicine in Paris extends over a period of five years. Bacteriologic laboratories are found in nearly all the Paris hospitals, and the internes or resident students are evidently familiar with their use, and are in every re- spect a very high class of men. They are thoroughly competent in the performance of their duties, and in the absence of the senior surgeons are almost daily called upon to perform many of the gravest operations of surgery. August 26 and 27, 1892, I visited, with Dr. Henri Hart- man, the Hopital Bichat, and there found what I con- sidered to be an ideal hospital. This hospital is small, consisting of only two wards, one for males and the other for females, and each containing about sixty beds. These wards are connected by an operating-ward con- taining ten or twelve beds. There are also the necessary administration buildings. This hospital is only used for operations and patients who are waiting their turn to be operated upon. I saw there aseptic surgery carried out with a perfection of detail and with such successful re- sults as I have certainly never seen equalled elsewhere. I saw there six cases of celiotomy in various stages of recovery after having been operated upon-cases of cholecystectomy, nephrectomy, vaginal hysterectomy, amputations, and indeed all the graver operations of surgery. Almost all the histories of the cases show re- covery without rise of temperature or suppuration. They start out in the Hopital Bichat with the assumption that if an operation is aseptically performed, by an aseptic operator, on an aseptic patient, there should then be neither fever nor suppuration following a surgical opera- tion. If rise of temperature takes place, the operator is at once attacked and blamed for imperfect surgery. If 6 an operator has three or four such cases in succession, they have a nickname for him; he is called cochon sale. Time will not permit me to describe all the interest- ing cases I saw. Among them was a case of ligation of the femoral artery on account of a traumatic aneurism, caused by erosion and penetration of the artery by a sharp exostosis on the femur. The artery was cut down upon and ligated above and below the injured portion with a successful result. Another case was one of necrosis involving nearly all the shaft of the femur. After the removal of an im- mense sequestrum, the cavity was filled with the fresh and aseptic bone of a calf, which was broken up about as large as coarsely ground coffee, and the cavity was filled with it, with the result of the formation of a firm and solid thigh-bone. This case was operated upon about six weeks before I saw him, and was about to be discharged cured. Another case of a similar kind was awaiting operation. Dr. Hartman acknowledged that he had received the idea of doing this from an American surgeon, Dr. Senn. On Saturday, August 27th, a woman was brought into the Hopital Bichat apparently dying; temperature 107.8°, pulse scarcely perceptible, and partly delirious. The case was one of suppurating ovarian cyst, which had burst into the cavity of the peritoneum. After wrapping her in hot blankets and administering stimu- lants, a slight reaction set in, and celiotomy was imme- diately performed. The next morning at 9 o'clock, I saw her and she was rational, the pulse nearly normal, and with scarcely any fever. It seemed almost like see- ing one raised from the dead. The methods of operating are of the simplest character. The arms and hands of the operator and his assist- ants are, of course, thoroughly cleansed with soap and solution of corrosive sublimate, 1 : 2000, as well as the part of the patient's body where the operation is to be 7 performed. As few instruments as possible are used, and these have been recently sterilized by boiling water, or dry heat at the temperature of 220° F. No sponges are used, their place being supplied by the use of balls of aseptic cotton. In the case of an amputation no ligatures are used for the vessels except such as silk- worm-gut or catgut, and these are cut short. No drain- age-tubes are used, or, in fact, anything that will prevent union by first intention. No plasters are used on the stump for fear of infecting the wound, as it is impossible to sterilize the usual adhesive plasters often used to keep the flaps of the stump in close apposition. The stump is dusted with iodoform, and iodoform-gauze is applied ; then a very liberal supply of aseptic cotton-wool, firmly retained by properly applied bandages. The operator must not, of course, touch anything from which infection might be conveyed to the wound. He is not allowed even to pass his hands over his own face, or to touch any part of his body with his hands during an operation. Such minute precautions as these may seem needless to some, but such is not the case, for, as has been well said, " Perfection is made up of trifles, but perfection is no trifle." After a somewhat long and varied experience in surgery, I must say that I have never seen such fineness of technique, and such mag- nificent results of surgery, as I beheld in the Paris hospitals. It is rare to find a surgeon in Paris who has attained any eminence before the age of fifty years, but Dr. Hartman, I am informed, is only thirty two years old, and is now acting as surgeon in three of the Paris hos- pitals. With my hearty good wishes, I venture to pre- dict for him a brilliant and useful career. Very respectfully yours, Robert Reyburn, M.D. 714 Thirteenth Street, Washington, D. C. The Medical News. Established in r8fj. A WEEKL YMEDICAL NE WSPAPER. Subscription, $4.00 per Annum. The American Journal OF THE Medical Sciences. Established in 1820 A MONTHLY MEDICAL MAGAZINE. 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