CHAPTER X. Antiseptics, Bacteriology, and Local anæsthesia

ANTISEPTICS, BACTERIOLOGY, AND LOCAL ANÆSTHESIA

Joseph Lister’s first paper on his method of preventing the access to wounds of germs which cause putrefaction appeared in the Lancet in 1867. It was not, however, until several years later that London surgeons began to adopt his methods, and it was not until the teaching and training of bacteriological laboratories exerted their influence that the practice of Listerian principles became generally and efficiently carried out.

Wounds of the eye, due to the protective influence afforded by the eyelids, and to their continuous irrigation with tears, which normally possess bactericidal powers, were less liable to septic infection than those in other parts of the body. Hence, prior to the introduction of antiseptic methods, the operations of ophthalmic surgery were less frequently complicated by septic troubles than those of general surgery.

Where the tear duct became obstructed and discharge from the tear sac regurgitated into the eye, and where contaminated instruments were introduced into the interior of the eyeball, wounds became infected and disastrous consequences ensued. The danger of operating for cataract when there was obstruction to the tear duct was soon recognised, and it became a routine practice to investigate the condition of the tear passages before embarking on such operations. It was not until some time after the introduction of antiseptic surgery that the sterilisation of the instruments used in ophthalmic operations became general.

In the third edition of Soelberg Wells’ Treatise on Eye Diseases, published in 1873, which may certainly be taken as picturing the high-water mark of ophthalmic practice at that date, no mention is made of the use of any antiseptic precautions in connection with operations on the eye.

The after-treatment of eyes operated on for extraction of cataract at Moorfields in 1876 is described by A. S. Morton, who was then house surgeon, as follows:

“As soon as the operation was completed the lids of each eye were fastened by a very narrow vertical strip of plaster to prevent involuntary opening of the eye during recovery from the anæsthetic, then a piece of lint, on which was placed a layer of cotton-wool for each eye, and over all a bandage. The eyes were dressed each morning and evening after the operation, being gently bathed with tepid water and the lids oiled with a soft brush to prevent the dressing sticking to them. The patients were kept in bed till the third day, and the lids never opened till the fourth or fifth day after the operation, unless there were indications of mischief. About the end of a week they were handed over to the nurse to dress, and in about nine or ten days were allowed to have their eyes open, but very carefully shaded.”

Confinement in a dark room was for a long time regarded as an essential part of the treatment of certain eye diseases. Some elderly people still retain vivid recollections of having to submit to this unpleasant form of treatment for some inflammatory eye affection in their youth. The admission of light to the eye during the first few days after an operation for cataract was believed to excite inflammation, and elaborate precautions were taken to avoid it.

The cataract wards at Moorfields were darkened with double blinds, and when the dressings on the eyes were being changed, a nurse stood at the end of the bed holding a candle which she cautiously shaded with her hand to prevent any of its rays falling on the patient’s eyes. Some of the senior members of the staff received rather a shock when a venturesome house surgeon, mindful of Florence Nightingale’s dictum that “a dark room is always a dirty room,” had the blinds in the cataract wards drawn up, letting the sun’s blessed rays stream in, whilst the patient’s eyes were tied up or shaded with dark glasses.

The practice with regard to the instruments in the pre-antiseptic days was for the nurse to wash them when used in ordinary tap-water, after which they were stored in their velvet-lined cases. From these they were transferred without further preparation, and handed to the surgeon for the next operation on a tray lined with green baize.

Out-patients and in-patients were operated on in the same theatre, the former coming to it just as they presented themselves at the Hospital, without any change of clothing. The surgeons themselves made no change in their costume when operating, and the nurses wore no regular uniform.

The former violent “antiphlogistic” treatment of extensive bleeding, sweating, vomiting, and purging, for inflammatory affections of the eyes, had in the seventies been given up, chief reliance being then placed on the use of belladonna and poppy-head fomentations, “astringents,” and the application of leeches, blisters, and setons to the temples.

The year 1872 was an unusually disastrous one at Moorfields as regards operations for the removal of cataract, as many as 20 per cent. having resulted in failure. A joint meeting of the Committee and the medical staff was held to consider the matter, and the disasters were attributed to the presence in the Hospital at the time of a large number of infectious cases, changes in the nursing staff, and the absence of the house surgeon on a holiday. Measures to improve the ventilation of the wards were taken, an assistant house surgeon was appointed, and a long standing request of the Medical Council for the appointment of a special night nurse was at last acceded to.

At the International Congress of Medicine held in London in 1881, a discussion took place at the ophthalmological section on the employment of antiseptics in ophthalmic surgery. Antiseptic surgery at that time consisted in the use of carbolic acid in the form of a spray, as a lotion, and in the dressings. Professor Horner of Zurich, who opened the discussion, quoted his statistics of cataract operations from 1867 to 1881 to show that by the use of antiseptics there had been a decrease in the number of cases of suppuration from 6·6 to 1·1 per cent. Some speakers thought the good obtained from the use of carbolic acid was counter-balanced by its irritating properties. Bowman, who presided over the section, in his Inaugural Address, made the following wise remarks which may be taken as foreshadowing the adoption of aseptic as opposed to antiseptic measures:

“I presume that no one nowadays will question the evils we are so familiar with in our practice, and which have so often marred the intention of well-devised operations skilfully performed, but where, as we hear it said, Nature has failed to do her part, to second the effort of the surgeon by a process of repair. The study of the causes of such failures and of the means of obviating them, constitutes far the most brilliant page of modern surgery; and in other sections of this Congress, while the name of Lister will be applauded, the wide questions he has raised, and in raising has so often cleared up, will receive the full consideration they call for.

“In the case of the organ of sight, specially constituted, and in some respects screened from injury as it unquestionably is, there are reasons why the application of precautionary antiseptic measures, though the principle of them must still assert itself, should take a somewhat special form. Owing to the local structural conditions they may apparently be often more simple, though the possible need of the more elaborate of them should never be allowed to fall out of view.

“The tears are a secretion as pure from extraneous particles as is the filtered air in the recesses of the lungs. They are poured out under cover, in the right place, in quantity suitable to the need; while the lids diffuse them over the conjunctival surface ere they escape to their proper channels. Their useful and multiple office is performed in a way so simple and so perfect, that no art, however skilful, could pretend to equal it. We should ponder well the deep marvels of adaptation of means to ends, and take heed that we do not hinder exquisite Nature by meddlesome or needless interference, by the nimia diligentia Chirurgorum, but only lend it tender and judicious help by our dressings and our methods. We should always still be able to apply the words of our great poet, ‘The Art itself is Nature.’”

In 1876 A. S. Morton, the house surgeon at Moorfields, recorded that out of 146 cases of extraction of cataract 5·47 per cent, had suppurated, and that 12·3 per cent, had suffered from severe iritis. In an analysis of the results of cataract extraction at Moorfields for five years, from 1889 to 1893, the house surgeon, C. D. Marshall, records the number in which suppuration occurred as 1·69 per cent. The preparation and after-treatment of patients undergoing this operation during those years he describes as follows:

“I shall here only mention the special points connected with the eye, the general examination and preparation of the patient being precisely the same as that adopted previous to the performance of any surgical operation. The lids and parts around the eye are carefully washed with soap and hot water over-night, and a pad which has been wrung out in a 1/4000 solution of the perchloride of mercury is applied. On removing this the next morning one is able to obtain a good idea as to the state of the conjunctiva; if the lids be gummed together, the operation is deferred until a more satisfactory state of things is obtained. If, however, there is nothing to contraindicate the performance of the operation the eye is anæsthetised with a 2 per cent. solution of freshly prepared cocaine and the conjunctival sac is washed out with a good stream of either warm boracic or perchloride lotion. The instruments are boiled before being used and kept in carbolic acid lotion 1 to 40.

“After the operation both eyes are as a rule closed for a day or two, and tied up with pads of Gamgee tissue made of the double cyanide wool. The operated eye is kept bandaged for about a week, and after that dark goggles are worn.”

John Couper, who was a general surgeon at the London Hospital as well as an ophthalmic surgeon at Moorfields, was one of the earliest and most enthusiastic pioneers of antiseptic surgery, practising it consistently before Lister came to London. At Moorfields he was one of the first to welcome its application to ophthalmic surgery.

PLATE XX.

In the following appreciation, written by Sir John Tweedy, we have recorded a most faithful and striking word-picture of John Couper’s characteristics:

“When I first knew John Couper he was assistant-surgeon to the London Hospital and assistant-surgeon to the Royal London Ophthalmic Hospital, Moorfields. With his work as a general surgeon I was but slightly acquainted, but I do know that he was one of the first and most ardent of the disciples of the Listerian doctrine, and practised the Listerian method with patient confidence. It was my happy privilege to have as colleagues at Moorfields George Lawson and John Couper, and to work side by side with them for many years. Lawson was one of the best ophthalmic surgeons I have ever known. Couper’s gifts were of a different order. Although a good surgeon and skilled operator, his qualities were those of an ophthalmic physician. Facile princeps among the ophthalmoscopists of the day, he was one of the first in this country seriously and scientifically to study problems of the errors of refraction, and especially of astigmatism. His diagnostic skill and his careful method of investigation attracted a body of thoughtful pupils, not a few of whom afterwards attained a notable distinction. Couper’s was a charming personality; he was gentle, courteous, conciliatory, but strong in opinion and tenacious of principle. His mental temperament was essentially sceptical. Not unbelief, not mis-belief, but hardness of belief was his intellectual attitude to all surgical and scientific questions. He did not believe easily or lightly, but only when convinced by the force of reason and by the potency of well observed facts. His scepticism may not have been an unmixed benefit as a teacher to beginners, but it was a real advantage at a Hospital like Moorfields, where many of the pupils, assistants, and visitors were actual or potent experts. His hardness of belief often provoked keen but friendly controversy, sharp but generous differences of opinion, which rarely failed to elucidate truth, and open up fresh avenues of knowledge. No man was ever the worse for a difference of opinion with Couper, and most of us were often much the better. Thought was stimulated, reasons were clarified, opinions modified and amended, or maybe strengthened and confirmed; and, above all, a valuable lesson was learnt in mutual respect and tolerance. Couper was indeed a lovable man, a true friend, a staunch and loyal colleague. To have known him, and to have been so long associated with him, is an abiding satisfaction, and the recollection of a friendship unclouded throughout many years is a precious possession.”

John Couper was not only a pioneer in the use of antiseptics in ophthalmic surgery, but also in the accurate correction of even small errors of refraction with glasses. He was most emphatic and uncompromising in advising his patients to wear their glasses constantly. A young lady with a very pretty face, who felt very loath to detract from its charms by wearing glasses, asked pitifully: “Please, Mr. Couper, how long shall I have to wear these glasses?” Couper replied by asking her her age, which was eighteen. “Well,” said Couper, “the average age of woman is three score years and ten: eighteen from that makes how long?”

Couper made use of his ophthalmoscope not only to explore the fundus of the eye, but also as an optometer for the estimation of refractive errors. He commenced to do so before the practice of “retinoscopy” came into use, and having acquired considerable skill in the method, continued to employ it in preference to the easier one. To render the ophthalmoscope as serviceable as possible as an optometer, he introduced several modifications in it. He found it most desirable to have only one lens to look through behind the sight hole in the mirror at a time, and to be able to bring the eye of the observer as near as possible to that of the one being examined. For these purposes he substituted a chain of lenses in place of the usual disc, and, as he considered it necessary to have as many separate lenses available as are contained in an ordinary trial case, the handle of his ophthalmoscope in which the lenses circulated became of considerable length. So long, indeed, was it that Couper had to arrange with his tailor for the construction of a special coat pocket in which he could carry it.

The method of estimating errors of refraction of the eye by what is now known as “retinoscopy” was first introduced as a systematic method by Cuignet in 1874, under the inappropriate name of “keratoscopy.” Bowman had, however, ten years previously called attention to the possibility of diagnosing regular astigmatism by using the mirror of the ophthalmoscope to reflect light into the eye, much in the same way as for detecting slight degrees of conical cornea.

An article advocating the use of Cuignet’s method, by Litton Forbes, appeared in the Ophthalmic Hospital Reports in 1880, and another, descriptive of its optical basis, by W. Charnley, in 1882.

In 1883 John Cawood Wordsworth, having reached the age of sixty, retired from the active staff after thirty-one years of service, and died three years later from angina pectoris. He was described as an admirable example of the genuine “dignity and reputation of the profession,” and as “unobtrusive almost to a fault.” Though, together with Hutchinson, he was for several years editor of the Hospital Reports, he contributed but little himself to the literature of ophthalmology.

He resided and commenced to practise in Finsbury Square; for some time his private patients were but few and far between. He employed a page boy who was instructed to fetch him from the Hospital if any patient should happen to come whilst he was engaged there. One day the boy came to the Hospital in hot haste to announce the arrival of a patient. “Will he wait until I get round?” Wordsworth asked the boy. “I am quite sure he will,” replied the boy, “for I have locked him in.” Wordsworth then explained to the house surgeon and his assistants how they must carry on the work for a time as he had been called away to see a private patient; they helped him on with his coat, and away he went with the boy. To their great surprise he returned after only a few minutes. Noting the surprised look in their faces, he sadly explained that it was only the tax collector.

Marcus Gunn, who had previously been the house surgeon, was appointed to succeed Wordsworth; he was the first officer who had so served the Hospital to become elected as a member of its honorary staff. He had been a particularly able and energetic house surgeon, having instituted a new system of note-taking for the in-patients, which has proved so satisfactory that it is still in use at the present time. His intimate acquaintance with the nursing and domestic arrangements of the Hospital proved of considerable value in the reforms and general upheaval which took place shortly after he was appointed. Previous to his becoming house surgeon, he had studied ophthalmology in Vienna under Jaeger; so impressed was he with the systematic courses of instruction carried on at that school, that on his appointment as assistant-surgeon he at once set to work to institute more regular and systematic teaching at Moorfields. He himself conducted regular classes in ophthalmoscopic examination at stated intervals, which became so popular that the list of students which could be taken at any one class was always filled up some time in advance.

PLATE XXI.

Early in 1884 Dr. Martin resigned the post of physician, and Dr. Stephen Mackenzie (afterwards Sir Stephen Mackenzie), a physician at the London Hospital, was appointed in his place. He resided at that time in Finsbury Square, and it was easy, therefore, for him to attend at the Hospital when requested to do so either by a member of the surgical staff or the house surgeon. He took a keen interest in medical ophthalmology, and contributed several communications on the subject to the Ophthalmological Society, of which he was one of the first secretaries.

During a large part of the nineteenth century the district of Finsbury was a fashionable residential medical quarter of London; Finsbury Square, Finsbury Pavement, Finsbury Circus, Broad Street, and St. Helen’s Place, at one time swarmed with physicians and surgeons. The City and its adjacent districts were then largely inhabited by prosperous business folk and their families; as these migrated westwards, the doctors naturally followed suit. Many of the younger members of the staffs of St. Bartholomew’s, Guy’s and the London Hospital lingered on so as to be within easy distance of those Institutions. It gradually became the custom for those residing around Moorfields Hospital, who were interested in ophthalmology, to foregather there in the house surgeon’s room on certain evenings in the week to discuss cases and other matters of mutual interest. So far back as 1866 Jonathan Hutchinson records in the Ophthalmic Hospital Reports how he read a paper at the “Moorfields Club,” It was at one of such informal meetings that early in 1880 a circular was drawn up suggesting the formation of an Ophthalmological Society. This was sent to the leading ophthalmic surgeons in the three divisions of the United Kingdom, and met with a cordial response. In June of that year the first meeting of “The Ophthalmological Society of the United Kingdom” was held, at which William Bowman, who had been appointed President, delivered an Inaugural Address.

Pasteur’s researches on fermentation and putrefaction, and Lister’s application of them to the treatment of wounds, raised the study of bacteriology to the dignity of a science.

Improvements in the microscope by the introduction of high power oil-immersion lenses made it possible to study the morphology of micro-organisms, and the introduction by Koch of improved methods for obtaining pure cultivations of them paved the way to the investigation of their life-history and bio-chemical reactions.

During the eighth decade of the nineteenth century the connection of several different micro-organisms with diseases of the eye was discovered, which aided in the study of their natural history and treatment.

In 1884 incubators and other bacteriological apparatus were installed in the pathological laboratory at Moorfields to allow of these new methods of investigation being carried out.

In 1882 Koch demonstrated that a specific organism could be separated from tuberculous tissue and cultivated outside the body, which would reproduce tuberculosis when inoculated. A new test was thus supplied for the recognition of tuberculous lesions, and some affections of the eye, of which the real nature up to that time had been doubtful, were by its means proved to be tubercular. J. B. Lawford, who, on the resignation of Jennings Milles, had become curator of the Museum, was among the first to detect Koch’s bacillus in the tissues of the eye.

In 1890 Koch introduced his original form of tuberculin treatment, which, before its effects had been adequately investigated, raised the greatest expectations, and caused a rush to Berlin of consumptives from all parts of the world. This treatment was tested in January, 1891, on a patient at Moorfields, under Waren Tay, with tubercular nodules in the iris at the margin of the pupil. So situated it was possible to watch the effects of the treatment on them with the greatest precision. The nodules, which were at first separate, gradually increased in size and became confluent, ultimately invading neighbouring parts and necessitating the removal of the eye. Besides demonstrating the failure of the treatment, this case was of interest, because the administration of an injection of the tuberculin after the eye was removed produced a general reaction, thus showing the presence of some other focus of tuberculosis which had not been detected, and from which most probably the eye had become secondarily affected.

PLATE XXII.

From a painting by a patient upon whom he had performed the operation of extraction of cataract.]

The employment of bacteriological investigation in connection with the discharge from eyes affected with ophthalmia resulted in the discovery of two new forms of bacilli—the Koch-Weeks bacillus in 1887, and the Morax-Axenfeld diplo-bacillus in 1896—each receiving a dual name due to their independent and almost simultaneous recognition by two different workers.

The recognition of these and other micro-organisms which had been discovered in connection with other affections (such as the gonococci, Klebs-Löffler bacilli, pneumococci, streptococci, and staphylococci), as the specific agents in the causation of the different forms of ophthalmia, led to a new means of classifying them, the previous classifications being based on the clinical appearances alone.

The rapid advance in bacteriology, and the introduction of vaccine treatment arising out of it, tended to make its study and practice more and more a special branch of medicine. In 1907, after the Hospital had been removed to the City Road, it was found necessary to erect a special laboratory for its development and to appoint a special officer to take charge of it.

The premature decease of several members of the surgical staff just as they had attained the acme of a successful career has already been referred to; the cruellest fate of all was that which befell James Adams, who, whilst engaged in restoring and saving the sight of others, was doomed to watch the gradual failure of his own to complete and irremediable blindness. This, too, whilst he was in the hey-day of life, a successful general surgeon at the London Hospital and ophthalmic surgeon at Moorfields. A man full of the joy of life, deservedly popular with his colleagues and students, he combined scientific with spotting interests, and was able to snatch a day here and there from his arduous duties to follow the hounds.

A complete rest having failed to prove of any benefit to his gradually increasing darkness, he, in the latter part of 1884, found it necessary to resign all his appointments. William Lang, who had for some time worked with him as clinical assistant, and who held the appointment of ophthalmic surgeon at the Middlesex Hospital, was elected as his successor at Moorfields.

Cocaine is derived from the leaves of a plant, Erythroxylon coca, which grows in Peru and Bolivia. It was originally named “khoka,” meaning “the tree of trees.” Joseph de Jussieu first sent a specimen of the plant to Europe in 1750. The practice of chewing its leaves as a means of appeasing hunger and thirst, and relieving fatigue, had for long been a custom among the natives of South America. The famous long-distance walker, Weston, employed them in this way when, in the seventies, he trudged round and round the Agricultural Hall in his efforts to cover the longest possible distance in the shortest possible time. In 1872 Dr. Hughes Bennett of Edinburgh showed that cocaine, when applied to a mucous membrane, produced anæsthesia, but no use was made of it in practice.

It was Karl Roller of Vienna, in 1884, who first made applications of it to the eye, which resulted in its employment in ophthalmic surgery. Koller’s original article, describing the physiological effects of the drug on the eye, was so complete that there was but little left to be added. A description of it was given at the meeting of the Heidelberg Ophthalmological Society in 1884, and a solution of the drug was brought straight from there to Moorfields in the latter part of September of that year. The first operation performed under its influence in this country was a tattooing of the cornea by Marcus Gunn. Its employment soon became general in all operations on the eye in which there was not much congestion, and in which the tension of the globe was not increased. The supply at first was so small and the demand so great that its price rapidly rose to a guinea a grain.

The substitution of local for general anæsthesia in cataract operations aided materially in their safety and success. The dreaded effects on the eye of vomiting and reaching on the recovery from the administration of ether or chloroform were avoided, and the aid of the patient in turning the eye in any direction did away with the necessity of dragging it into suitable positions, which was frequently requisite when the patient was unconscious. The immediate result was a considerable decrease in the number of cases in which the vitreous humour escaped, and the possibility of greater precision in the adjustment of parts after the removal of the cataract.

At first nothing was known of its toxic effects, and the small amount absorbed when dropped into the eye did not give rise to them. It was only when attempts were made to anæsthetise large areas of the skin by subcutaneous injection that they became manifest.

In 1884 the surgical staff had become so dissatisfied with the system of nursing at the Hospital, and with the standard of the nurses employed, that they requested a conference with the Committee of Management on the matter. At this conference it was agreed that no satisfactory improvement could be effected without having at the head of the establishment a lady who had herself been efficiently trained as a nurse. Miss Harnet, who then held the post of matron, was advised to tender her resignation. This she did, a pension being granted her. The new matron, selected from a number of candidates for the post, was Mrs. Peel, who had been trained at the London Hospital, where she had also held the post of sister: later she had been matron at the Newcastle Infirmary.

Shortly after her appointment, the head nurse was detected receiving money from a patient; this being her second offence of the sort she was at once dismissed. After her departure it was discovered to have been a common form of corruption, notwithstanding the warning notices concerning it posted about the Hospital. The forced resignation of the former matron and the summary dismissal of the head nurse caused consternation amongst the other members of the nursing staff, who combined together to make things unpleasant for the new matron. She received, however, the support of the medical staff and the Committee of Management, and ultimately a complete change of the nursing staff was effected, fully trained nurses being engaged to fill all the most important posts.

In April, 1885, occurred the sudden and unexpected death of Streatfield, who was at that time the senior surgeon. As has already been mentioned, he was a most dexterous operator, and also possessed of considerable ingenuity, which manifested itself sometimes in peculiar ways. A few years before his death he had had constructed a gigantic model of an eye, on which he could demonstrate to students mechanically the various stages of operative procedures. As he truly pointed out, in operations on the eye, the smallness of the organ and of the parts dealt with renders it impossible for any, except those in close proximity to the operator, to see clearly what is taking place. He, therefore, devised this model, constructed with all its dimensions ten times the size of the normal eye. The eyelids and sclerotic were of white felt spread over wire, the cornea of glass, the iris of indiarubber, the lens of xylonite, and the external muscles of the eye of linen. Models of the instruments employed were of wood, also ten times their actual size, except as regards their handles, which to allow of the manipulation of such weapons had to be reduced. By various artfully arranged mechanical contrivances, the lens could be made to present and escape from the eye above the cornea when a certain spot on the sclerotic was touched, and the cornea then roll back into position. Ingenious as all these contrivances were, the effect of the model when exhibited was to excite mirth more than anything else. It passed into the possession of the Hospital after Streatfield’s death, but no further use was made of it.

PLATE XXIII.

A. Quarry Silcock was elected to succeed Streatfield; besides being an ophthalmic surgeon he was a general surgeon attached to St. Mary’s Hospital. At one time, as has been shown, all members of the surgical staff of the Hospital had to be either a general surgeon or a demonstrator of anatomy connected with a general hospital. This rule had, however, been altered, it being thought only necessary to insist on candidates possessing the diploma of Fellowship of the College of Surgeons of England, as a guarantee that they had attained a high standard of general surgical efficiency. Silcock was the last member of the staff appointed who combined the practice of ophthalmology with that of general surgery; all those since appointed, though Fellows of the College of Surgeons, have restricted their practice to ophthalmology. With the growth of knowledge the speciality of ophthalmology had come to consist of much besides mere dexterity in the performance of certain surgical operations. Here may be aptly quoted what the late Dr. James Anderson wrote with reference to it in 1889:

“It seems to me the best and most hopeful feature of ophthalmology that it has relations, closer or more remote, with every branch of medicine and surgery—indeed, with almost every branch of science.”