GERM-FOES THAT FOLLOW THE KNIFE, OR DEATH UNDER THE FINGER-NAIL

Our principal dread of a wound is from fear that it may fester instead of healing quickly. We don’t exactly enjoy being shot, or stabbed, or scratched, though, as a matter of fact, in what Mulvaney calls the “fog av fightin’” we hardly notice such trifles unless immediately disabling. But our greatest fear after the bleeding has stopped is lest blood-poisoning may set in. And we do well to dread it, for in the olden days,-that is, barely fifty years ago,-in wounds of any size or seriousness, two-thirds of the risk remained to be run after the bleeding had been stopped and the bandages put on. Nowadays the danger is only a fraction of one per cent, but till half a century ago every wound was expected to form “matter” or pus in the process of healing, as a matter of course. Most of us can recall the favorite and brilliant repartee of our boyhood days in answer to the inquisitive query, “What’s the matter?” “Nuthin’: it hasn’t come to matter yet. It’s only a fresh cut!”

Even surgeons thought it a necessary part of the process of healing, and the approving term “laudable pus” was applied to a soft, creamy discharge, without either offensive odor or tinge of blood, upon the surfaces of the healing wound; and the hospital records of that day noted with satisfaction that, after an operation, “suppuration was established.” So strongly was this idea intrenched, that a free discharge or outpouring of some sort was necessary to the proper healing of the wound, that in the Middle Ages it was regarded as exceedingly dangerous to permit wounds to close too quickly. Wounds that had partially united were actually torn apart, and liquids like oil and wine and strong acids, which tended to keep them from closing and to set up suppuration, were actually poured into them; and in some instances their sides were actually burned with hot irons. There was a solid basis of reason underlying even these extraordinary methods, viz., the “rule of thumb” observation, handed down from one generation to another, that wounds that discharged freely and “sweetly,” while they were slow in healing and left disfiguring scars, usually did not give rise to serious or fatal attacks of blood-poison or wound-fever. And of two evils they chose the less. Plenty of pus and a big ugly scar in preference to an attack of dangerous blood-poisoning. Even if it didn’t kill you, it might easily cripple you for life by involving a joint. The trouble was with their logic, or rather with their premises. They were firmly convinced that the danger came from within, that there was a sort of morbid humor which must be allowed to escape, or it would be dammed up in the system with disastrous results.

One day a brilliant skeptic by the name of Lister (who is still living) took it into his head that perhaps the fathers of surgery and their generations of imitators might have been wrong. He tried the experiment, shut germs out of his wounds, and behold, antiseptic surgery, with all its magnificent line of triumphs, was born!

Now a single drop of pus in an operation wound is as deep a disgrace as a bedbug on the pillow of a model housekeeper, and calls for as vigorous an overhauling of equipment, from cellar to skylight; while a second drop means a commission of inquiry and a drumhead court-martial. This is the secret of the advances of modern surgery,-not that our surgeons are any more skillful with the knife, but that they can enter cavities like those of the skull, the spinal cord, the abdomen, and the chest, remove what is necessary, and get out again with almost perfect safety; whereas these cavities were absolutely forbidden ground to their forefathers, on account of the twenty, forty, yes, seventy per cent death risk from suppuration and blood-poison.

The triumphs of antisepsis and asepsis, or keeping the “bugs” out of the cuts, have been illustrated scores of times already by abler pens, and are a household word, but certain of its practical appliances in the wounds and scratches and trifling injuries of every-day life are not yet so thoroughly familiar as they should be. When once we know who our wound-enemies are, whence they came, and how they are carried, the fate of the battle is practically in our own hands.

Like most disease-germs our wound-infection foes are literally “they of our own household.” They don’t pounce down upon us from the trees, or lie in wait for us in the thickets, or creep in the grass, or grow in the soil, or swarm in our food. They live and can live only within the shelter of our own bodies, where it is warm and moist and comfortable. This is one great (in the expressive vernacular) “cinch” that we have on the vast majority of disease-germs, whether medical or surgical, that they do not flourish and breed outside of the body, or of houses closed and warm; and this grip can be improved, with skill and determination, into a veritable strangle-hold on most of them. In the language of biology, most of them have become “adapted to their environment” so closely that they can scarcely flourish and breed anywhere outside of the warm, moist, fertile soil of a living body, and many of them cannot even live long at temperatures more than ten degrees above or fifteen degrees below that of the body. At all events, so poorly are these pus-germs able to preserve their vigor and power of attack, not merely outside of the human body, but outside of some wound or sore spot, that it is practically certain that eight-tenths of all cases of wound-infection or blood-poisoning come directly from some previous festering wound, sore, ulcer, scab, boil, or pimple, in or on some other human being or animal. Practically whenever we get pus in a wound in a hospital, we insist upon finding the precise previous case of pus from which that originated, and seldom is our search unsuccessful. If we kept not only our wounds surgically clean, but our gums, noses, throats, skins, and fingernails, and burned and sterilized everything that came in contact with a sore, pustule, or scab, we should wipe out nine-tenths of our cases of wound-infection and suppuration; in fact, practically all of them, except such small percentage as may come from contact with infections in animals. This is the reason why, up to half a century ago, by a strange paradox hospitals were among the most dangerous places to perform operations in, on account of the abundance of wounds or sores always present for the pus-germs to breed in, and the fact that out of fifty or more wound-cases, there was practically certain to be one or two infected ones to poison the whole lot.

Surgeons, ignorant of antisepsis, and careless nurses, spread the infection along, until in some instances it reached a virulence which burst into the dreaded “hospital gangrene.” This dread disease was the scourge of all hospitals, especially military ones, all over the civilized world, as recently as our War of Secession. In some wards of our military hospitals, from thirty to fifty per cent of all the wounded received were attacked, and over five thousand cases were formally reported during the war, of which nearly fifty per cent died. This plague was born solely of those two great mothers of evils, ignorance and dirt, and is to-day, in civilized lands, as extinct as the dodo. Then the dread that the community had of hospitals, as places that “help the poor to die,” in Browning’s phrase, had a certain amount of foundation; and cases operated upon in a farmhouse kitchen, where no one in the family happened to have had a boil or a catarrh or a festering cut within a month or so, and where the knife happened to be clean or new, would recover with less suppuration than hospital cases. Nowadays, from incessant and eternal vigilance, a hospital is surgically the cleanest and safest place in the world for an operation, so that most surgeons decline to operate outside of one, except in emergencies; and some will not even operate except in one with which they are personally connected, so that they know every step in the process of protection.

It was this terrible risk of the surgeon carrying infection from one case to another, that made the coroner of London declare, barely sixty years ago, that he would hold an inquest upon the next case of death after ovariotomy that was reported to him, on account of the fearful pus-mortality that followed this serious operation, which now has a possible death-rate from all causes connected with the operation of only a fraction of one per cent.

The brusque reply is still remembered of Lawson Tait, the great English ovariotomist, to a distinguished German colleague, who had inquired the secret of his then marvelously low death-rate: after a glance at the bands of mourning on the ends of the other’s fingers, he said, “I keep my fingernails clean, sir!” There was sadly too much truth in the saying of another eminent surgeon, that in the pre-Listerian days many a poor woman’s death warrant was written under the fingernails of her surgeon. This reproach has been wiped out, thank Heaven! but the labor, pains, and persistence after heart-breaking failures which it took to do it! Never was there a more vivid illustration of the declaration that genius is the capacity for taking pains, than antiseptic surgery! Not a loophole must be left unstopped, not a possibility unconsidered, not a thing in, or about, or connected with, the operating-room left unsterilized, except the patient and the surgeon; and these are brought as near to it as is possible without danger to life.

In the first place, the operating-room itself must be like a bath room, or, more accurately, the inside of a cistern. Walls, floor, and ceiling are all waterproof and capable of being washed down with a hose. There must be no casings or cornices of any sort to catch dust; and in the best appointed hospitals no one is permitted to enter, under any pretext, whose hands and garments have not been sterilized.

In the second place, everything that is brought into the room for use in, or during, the operation, is first thoroughly sterilized. The knives, instruments, and other operative objects are sterilized by boiling, or by the use of superheated steam; and the towels, dressings, bandages, sheets, etc., by boiling, baking, or superheated steam. Then begins the preparation of the surgeon and the nurse. Dressing-rooms are provided, in which the outer garments are removed, and the hands given an ordinary wash. Then the scrubbing-room is entered, where, at a series of basins provided with running hot and cold water, whose faucets are turned by pressure with the foot so as to avoid any necessity for touching them with the hand, the hands are thoroughly scrubbed with hot water, boiled soap, and a boiled nail-brush. Then they are plunged into, and thoroughly soaked in, some strong antiseptic solution, then washed again; then plunged into another antiseptic solution, containing some fat solvent like ether or alcohol, to wash off any dirt that may have been protected by the natural oil of the skin. Then they are thoroughly scrubbed with soap and hot water again, to remove all traces of the antiseptics, most of which are irritating to wounded tissues; then washed in absolute alcohol, then in boiled or distilled water. Then the nurse, whose hands are already sterilized, takes out of the original package in which it came from the sterilizing oven, a linen surgical gown or suit which covers the operator from neck to toes. A sterilized linen or cotton cap is placed upon his head and pulled down so that the scales or germs of any sort may not fall into the wound. Some surgeons of stout and comfortable habit, who are apt to perspire in the high temperature of an operating-room, will tie a band of gauze around their foreheads, to prevent any unexpected drops of perspiration from falling into the wound; while some purists muffle up the mouth and lower part of the face lightly in a similar comforter.

You would think that by this time the hands were clean enough to go anywhere with safety, but no risks are going to be taken. A pair of rubber or cotton gloves, the former taken right out of a strong antiseptic solution, the latter out of the sterilizing oven, are pulled carefully on by the nurse. Holding his sacred hands spread out rigidly before him, like the front paws of a kangaroo, the surgeon carefully edges his way into the operating-room, waiting for any doors that he may have to pass through to be opened by the nurse, or awkwardly pushing them with his elbow. In that attitude of benediction, the hands are maintained until the operation is ready to begin.

Then comes the patient! If his condition will in any wise permit, he has been given a boiling hot bath and scrub the night before, and put to bed in a sterilized nightgown between sterilized sheets. The region which is to be operated upon has, at the same time, been scrubbed and rubbed and flushed with hot water, germicides, alcohol, soap,-in fact, has gone through the same sacred ceremonial of cleansing through which the surgeons’ hands have passed; and a large, closely fitting antiseptic dressing, covering the whole field, has been applied and tightly bound. He is brought into a waiting-room and put under ether by an anæsthetist, through a sterilized mask; he is then wheeled into the operating-room, the dressing is removed, a thorough double scrub is again given, for “good measure,” to the whole area in which the wound is to be made. A big sheet is thrown over the lower part of his body, another over the upper part, a third, with an oval opening in the centre of it, thrown over the region to be operated upon. The instrument nurse takes a boiled knife out of a sterilized dish of distilled water, hands it to the surgeon, who takes it in his gloved hand, and the operation begins.

Now, if you can think of any possible chink through which a wandering streptococcus can, by any possibility, sneak into that wound, please suggest it, and it shall be closed immediately!

The intruders against whom all these preparations are made are two in number: Streptococcus pyogènes and Staphylococcus pyogènes-cousins, as you see, by their names. Their last (not family) name really means something, and is not half so alarming as it sounds, as it is Greek for “pus-making.” Their real family name, Coccus, which means a berry, was suggested, by their rounded shape under the microscope, to some poetically minded microscopist. Undesirable citizens, both of them! But the older, or Strepto, cousin is by far the more dangerous character and desperate individual, giving rise to and being concerned in nearly all the civilized and dangerous wound-fevers-septicaemia, erysipelas, etc. Staphylococcus is a milder and less harmful individual, seldom going farther than to produce the milder forms of festering, discharging, refusing to heal, pustules, etc. He is not to be given a yard of leeway, however, for if he can get a sufficient number of dirty wounds to run through, he can work himself up to a high degree of virulence and poisoning power. Indeed, this faculty of his may possibly furnish a clew as to how these pus-makers developed their power of living in wounds, and almost nowhere else. There is another cousin also, in the group, called Staphylococcus pyogènes albus, to distinguish him (albus, “white”) from the other two, who have the tag name aureus (golden). He is an almost harmless denizen of the surfaces of our bodies, particularly the mouths of the sweat-ducts, and the openings of the hair follicles. Under peculiarly favorable circumstances, such as a very big wound, an aggravated chafe, or the application of that champion “bug-breeder,” a poultice, he may summon up courage enough to attack some half-dead skin-cells and make a few drops of pus on his own account. He is the criminal concerned in the so-called stitch-abscesses, or tiny points of pus which form around the stitches of a big wound and in some of the smaller pimples which turn to “matter.” It is conceivable that this feeble and harmless white coccus may at some time have been accelerated under favorable circumstances to where he was endowed with “yellow” powers, and even, upon another turn of the screw, with strepto-virulence. But this is a mere academic question. Practically the only thing needful is to keep all the rascals out of every wound.

Now comes the question, how is this to be done? Fortunately it is not necessary to hunt out and destroy the pus-germs in their breeding-places outside of the human body. As we have seen, they do not long retain their vitality out of doors, or as a rule even in the dust of rooms and dirt of houses, unless the latter have been recently contaminated with the dressings of, or discharges from, wounds. There are two main things to be watched: first, the wound itself, and second, any unwashed or unsterilized part of your own or some other living body. Dirt of all sorts is a mighty good thing to keep absolutely out of the wound, but practically a whole handful of ordinary soil or dust rubbed into a wound might not, unless it happened to contain fertilizer of some sort, be half so dangerous as a single touch with a finger which had been dressing a wound, picking a scab out of the nose, rubbing an ulcerated gum, or scratching an itching scalp. If it be a cut on the finger, or scratch on the hand, for instance, don’t suck it, or lick it, unless you can give an absolutely clean bill of health to your gums and teeth. If not thoroughly brushed three or four times a day, they are sure to be swarming with germs of twenty or thirty different species, which not infrequently include one or both of the pus-germs. Indeed, the real reason why the bite of certain animals, and above all of a man, particularly of a “blue-gum nigger,” is regarded as so dangerous is on account of the swarms of germs that breed in any remnants of food left between the teeth or in the pockets of ulcerating gums. Many a human bite is almost as dangerous as a rattlesnake’s. The devoted hero who sucks the poison of the dagger out of the wound may be conferring a doubtful benefit, if he happens to be suffering from Rigg’s disease.

Don’t try to stop the bleeding unless it comes in spurts or the flow is serious. The loss of a few teaspoonfuls, tablespoonfuls, or, for the matter of that, cupfuls, of blood won’t do you any harm, and its free flow will wash out the cut from the bottom, and carry out most of the germs that may happen to be present on the knife or nail. If water and dressings are not accessible, let the blood cake and dry over the wound without disturbing it, even though it does look rather gory.

A slight cut with a clean knife, or other instrument, into which no dirt has been rubbed, will often require no other dressing than its own blood-scab. If, however, as oftener happens, you cannot be sure of the cleanness of the knife, tool, or nail, hold the wound under running water from a pump or tap (this is not germ-free, but practically never contains pus-germs), until the wound has been thoroughly washed out, wiping any gravel or dirt out of the cut with soft rags which have been recently washed, or baked in the oven; then dry with a small piece of linen, or white goods, put on a dressing of absorbent cotton such as can be purchased for a few cents an ounce at any drug store. Absorbent or surgical cotton makes a good dressing, because it both sucks up any fluids which might leak out of the wound, and forms a mesh-filter through which no germs can penetrate.

It is not advisable to use sticking-plaster for any but the most trivial wounds, and seldom even for these, for several reasons. First, because its application usually involves licking it to make it stick; second, because it must cover a sufficient amount of skin on either side of the wound to give it firm grip, and this area of skin contains a considerable number of both sweat-ducts and hair-follicles, which will keep on discharging under the plaster, producing a moist and unhealthy condition of the lips of the wound. Moreover, these sweat-ducts and hair-follicles will, as we have seen, frequently contain white staphylococci, which are at times capable of setting up a low grade of inflammation in the wound. A wound always heals better if its surfaces and coverings can be kept dry. This is why cotton makes such an ideal dressing, since it permits the free evaporation of moisture, a moderate access of air, and yet keeps out all germs.

If the cut or scratch is of any depth or seriousness whatever, or the knife, tool, or other instrument be dirty, or if any considerable amount of street-dust or garden-soil has got into the wound, then it is, by all means, advisable to go to a physician, have the wound thoroughly cleaned on antiseptic principles, and put up in antiseptic dressing. A single treatment of this sort, in a comparatively trifling wound which has become in any way contaminated, may save weeks of suffering and disability, and often danger of life, and will in eight cases out of ten shorten the time of healing from forty to sixty per cent. The rapidity with which a wound in a reasonably healthy individual, cleaned and dressed on modern surgical principles, will heal, is almost incredible, until it has actually been seen.

The principal danger of garden-soil or street-dust in a wound is not so much from pus-germs, though these may be present, as from another “bug”-the tetanus or lockjaw bacillus. This deadly organism lives in the alimentary canal of the horse, and hence is to be found in any dirt or soil which contains horse manure. It is, fortunately, not very common, or widely spread, but enough so to make it the part of prudence to have thoroughly asepticized and dressed any wound into which considerable amounts of garden-soil, or street-dust, have been rubbed. The reason why wounds of the feet and hands have had such a bad reputation, both for festering and giving rise to lockjaw, is that it is precisely in these situations that they are most likely to get garden-soil, or stable manure, into them. The classic rusty nail does not deserve the bad reputation as a wound-maker which it enjoys, its bad odor being chiefly due to the fact already referred to, that injuries inflicted by it are most apt to be in the palm of the hand, or in the sole of the foot, and hence peculiarly liable to contamination by the tetanus and other soil bacilli.

For some reason or other which we don’t as yet thoroughly understand, burns from a toy pistol in particular, and Fourth of July fireworks in general, seem to be peculiarly liable to be followed by tetanus. The fulminate used in the cap of a toy pistol, and the paper and explosives of several of the brands of firecrackers, have been thoroughly examined bacteriologically, but without finding any tetanus germs in them. So many cases of lockjaw used to follow the Fourth of July celebrations a few years ago, that Boards of Health became alarmed, and not only forbade outright the sale of deadly toy pistols, but provided supplies of the tetanus antitoxin at various depots throughout the cities, so that all patriotic wounds of this description could have it dropped into them when they were dressed. Since then, the lockjaw penalty which we pay for our highly intelligent method of celebrating the Fourth, has diminished considerably. It is probable that the mortality was chiefly due to infection of the ugly, slow-healing, dirty little wounds with city-dust, a large percentage of which, of course, is dried horse manure. What with the tetanus bacillus and the swarms of flies which breed chiefly in stable manure, and carry summer diseases, typhoid, diphtheria, and tuberculosis in every direction, it will not be long before the keeping of horses within city limits will be as strictly forbidden as pigpens now are.

So definite is the connection between the tetanus bacilli and the soil, that tetanus fields or lockjaw gardens are now recognized and listed by the health authorities, on account of their having given rise to several successive cases of the disease. Workers in such fields or gardens, who scratch or cut themselves, are warned to report themselves promptly for treatment with the tetanus antitoxin.

Apart from the tetanus germ, however, the problem of the treatment of wounds-while there should be perfect cleanliness, the spotlessness of the model housekeeper multiplied fivefold-is yet not so much a matter of keeping dirt in general out of the wound, as of keeping out that particular form of dirt which consists of or contains, discharges from some previous wound, sore, ulcer, or boil!

While both these pus-organisms can breed and flourish freely only in wounds or sores, this is but their starting-point where they gather strength to invade the entire organism. We used to make a distinction between those cases in which their toxins or poison-products got into the blood, with the production of fever, headache, backache, delirium, sweats, etc., which we term septicaemia, and other cases in which the cocci themselves were carried into the blood and swept all over the body by forming fresh foci, or breeding-places, which resulted in abscesses all over the body, which we call pyaemia. But now we know that there is no hard and fast line to be drawn, and that the germs get into the blood much more easily than we supposed; and the degree and dangerousness of the fever which they set up depend, first, upon their virulence, or poisonousness, and, second, upon the resisting power of the patient at the time. Anything which lowers the general health and strength and weakens the resisting power of the body will make it much easier for pus-germs to get an entrance into it, and overwhelm it; so that, after prolonged famines for instance, or among the population of besieged cities, or in armies or exploring expeditions which have been deprived of food and exposed to great hardship, the merest scratch will fester and inflame, and give rise to a serious and even fatal attack of blood-poisoning, erysipelas, hospital gangrene, etc. Famines and sieges in fact are not infrequently followed by positive epidemics of blood-poisoning, often in exceedingly severe and fatal forms.

It was long ago noted by the chroniclers that the death-rate from wound-fever among the soldiers of a defeated army was apt to be much greater than among those of the victorious one, and this was quoted as one of the stock evidences of the influence of mind over body. But we now know that armies are not beaten without some physical cause, that the defeated soldiers are apt to be in poorer physical condition to begin with; that they have often been cut off from their base of supplies, have made desperate forced marches without food or shelter in the course of their retreat; and, until within comparatively recent years, were never half so well treated or well fed as their captors.

As the invading germs pass into the body, they travel most commonly through the lymph-channels and skin; are arrested and threatened with destruction by the so-called lymphatic glands, or lymph-nodes. This is why, if you have a festering wound or boil on your hand or wrist, the “kernels” or lymph-nodes up in your armpit will swell and become painful. If the lymph-nodes can conquer the germs and eat them up, the swelling goes down and the pain disappears. But if the germs, on the other hand, succeed in poisoning and killing the cells of the body, these latter melt down and turn to pus, and we get what we call a “secondary abscess.”

The next commonest point of attack of these pus-germs, if they once get into the body, and by far the most dangerous, is the heart, as in rheumatism and other fevers. Some will also attack the kidneys, giving rise to albumin in the urine, while others attack the membranes of the joints (synovia) and cause suppuration of one or more joints in the body, which is very apt to be followed by very serious stiffening or crippling. So that, common, and, in many instances, comparatively mild as they are, the pus-germs in the aggregate are responsible for a very large amount of damage to the human body.

This is the way the streptococcus and staphylococcus behave in an open wound, or sore; but they have two other methods of operating which are somewhat special and peculiar. One of these is where the germ digs and burrows, as it were, underground, in a limited space, resulting in that charming product known as a boil, or a carbuncle. The other, where it spreads rapidly over the surface just under the skin, after the fashion of the prairie fire, producing erysipelas. In the first of these he behaves like the famous burrowing owl of our Western plains, who forms, with the prairie-dog, the so-called “happy family.” He never makes his own burrow, he simply uses one which is already provided for him by nature, and that is the little close-fitting pouch surrounding the root of a hair. Whether the criminal is a harmless native white coccus which has suddenly developed anti-social tendencies, or a Mongolian immigrant who has been accidentally introduced, is still an open question. The probabilities are that it is more frequently the latter, as, while boils are absolutely no respecters, either of persons or places, and may rear their horrid heads in every possible region of the human form divine, yet they display a very decided tendency to appear most frequently in regions like the back of the neck, the wrist, the hips, and the nose. One thing that these areas have in common is that they are liable to a considerable amount of chafing and scratching as by collars and stocks on the neck, and cuffs on the wrists, or of friction from belts, or pressure or chafing from chairs or saddles. When the tissues have been bruised or chafed after such fashion, especially if the surface of the skin has been at the same time broken, and any pus-organism is either present in the hair-follicle, like the white coccus, or rubbed into it by a finger or finger-nail which has just been sucked in the mouth, used to pick the nose, or possibly engaged in dressing some wound, or cutting meat, or handling fertilizer, then all the materials for an explosion are at hand.