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JOSEPH, BARON LISTER
PUBLISHED BY
HENRY FROWDE, MY:
OXFORD UNIVERSITY PRESS
AND
HODDER AND STOUGHTON
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——
————
y Lraefl oe a
C
oY
THE COLLECTED PAPERS
OF
JOSEPH, BARON LISTER
MEMBER OF THE ORDER OF MERIT
FELLOW AND SOMETIME PRESIDENT OF THE ROYAL SOCIETY
KNIGHT GRAND CROSS OF THE DANISH ORDER OF THE DANEBR
KNIGHT OF THE PRUSSIAN ORDRE POUR LE MERITE
ASSOCIE ETRANGER DE L’INSTITUT DE FRANCE
ETC. eEIc,
IN TWO VOLUMES
VOL; 1
OXFORD
AT THE CLARENDON PRESS
MDCCCCIX
OXFORD
PRINTED AT THE CLARENDON PRESS
BY HORACE HART, M.A.
PRINTER TO THE UNIVERSITY
TABLE OF CONTENTS
PART ITI. -THE ANTISEPTIC SYSTEM
On a New Method of Treating Compound Fracture, Abscess, &c., with Observations on the
Conditions of Suppuration
Lancet, 1867, vol. i, pp. 326, 357, 389, 507 ; : vol li, p. - 98.
On the Antiseptic Principle in the Practice of Surgery. A Paper read before the British
Medical Association in Dublin on August 9, 1867 ‘ ;
British Medical Journal, 1867, vol. ii, p. 246.
Illustrations of the Antiseptic System of Treatment in Surgery
Lancet, 1867, vol. ui, p. 668.
An Address on the Antiseptic System of Treatment in se a delivered before the Medico-
Chirurgical Society of Glasgow .
British Medical Journal, 1868, vol. u, op TOT, sone a : he ri lL, Ps 368
Observations on Ligature of Arteries on the Antiseptic System
Lancet, 1869, vol. i, p. 451. Corrected February 1870.
An Address on the Catgut Ligature, delivered before the Clinical Society of London,
January 28, 1881 . : ‘ : : ;
Clinical Soctety’s meine al XIV.
Note on the Preparation of Catgut for Surgical Purposes .
British Medical Journal, 1908, vol. 1, p. 125.
On the Effects of the Antiseptic System of Treatment upon the Salubrity of a Surgical Hospital
Lancet, 1870, vol. i, pp. 4, 40.
Remarks on a Case of Compound Dislocation of the Ankle with other Injuries ; illustrating
the Antiseptic System of Treatment
Edinburgh, March 26, 1870 (Pamphlet).
Further Evidence regarding the Effects of the Antiseptic System of Treatment upon the
Salubrity of a Surgical Hospital. , ; ; : .
Lancet, 1870, vol. ii, p. 287.
A Method of Antiseptic Treatment applicable to Wounded Soldiers in the present War
British Medical Journal, 1870, vol. ii, p. 243.
On a Case illustrating the present Aspect of the Antiseptic Treatment in Surgery
British Medical Journal, 1871, vol. i, p. 30.
The Address in Surgery delivered on August 10, 1871, to the Thirty-ninth Annual Meeting
of the British Medical Association held in Plymouth
British Medical Journal, 1871, vol. ii, p. 225.
PAGE
I
IOI
IIg
IOI
105
vi CONTENTS
PAGE
On Antiseptic Dressing under some Circumstances of eee including Amputation at
the Hip-joint : : : : : 2 gO
Edinburgh Medical Vonmae so) XV, rey p- Tg.
On Recent Improvements in the Details of Antiseptic Surgery. : : : « 206
Lancet, 1875, vol. i, pp. 365, 401, 434, 468, 603, 717, 787.
An Address on the Effect of the Antiseptic Treatment upon the General Salubrity of Surgical
Hospitals, delivered in opening the ae Section of the British Medical Association in
Edinburgh, August 4, 1875 . : : : : , ‘ sae a7
British Medical Journal, 1875, “ait 1 Ob 760.
Demonstrations of Antiseptic Surgery before Members of the British Medical Association . 256
Edinburgh Medical Journal, vol. xxi, 1875-6, pp. 193, 481.
An Address on the Treatment of Wounds, delivered before the Surgical Section of the
International Medical Congress, London, August, 1881. ‘ : : ‘ 3) L275
Lancet, 1881, vol. ii, pp. 863, gor.
Transactions of the International Medical Congress, London, 1881, vol. ii, p. 369.
An Address on Corrosive Sublimate as a Surgical Dressing, delivered at the sae rae
of the Medical Society of London, October 20, 1884 ; : 5 203
British Medical Journal, 1884, vol. ii, p. 803.
An Address on a new Antiseptic Dressing, delivered before the Medical Society of London,
November 4, 1889 . 5 5 : : : . : ; ; » 309
Lancet, 1889, vol. ii, p. 943.
Further Observations on the Cyanide of Zinc and Mercury. Read before the Hunterian
Society, November 27, 1889 . : : : : : : : ; : - 324
Lancet, 1890, vol. 1, p. I.
Note on the Double Cyanide of Mercury and Zinc as an Antiseptic Dressing, contributed by
Lord Lister to Sir Hector Cameron’s Dr. James Watson Lectures, Glasgow, 1907 . 2? 320
British Medical Journal, 1907, vol. i, p. 795. Together with a later Note.
An Address on the present Position of pice Sieg delivered before the International
Medical Congress, Berlin, 1890 f : ‘ . ; : E332
British Medical Journal, 1890, vol. li, p. 577,
On the Principles of Antiseptic Surgery . : : : ; ‘ 5 , ‘ - 340
Virchow-Festschrift, Bd. iii (1891).
An Address on the Antiseptic Management of Wounds . ; 349
British Medical Journal, 1893, vol. i, pp. 161, 277, 337, with SRISEQUEntE Comecuene
On some Points in the History of Antiseptic Surgery ‘ : ; f : § 2 305
Lancet, 1908, vol. 1, p. 1815.
British Medical Journal, 1908, vol. i, p. 1557.
CONTENTS
PARE IV. SURGERY
Report of some Cases of Articular Disease occurring in Mr. Syme’s Practice, exemplifying the
Advantages of the Actual Cautery
Monthly Journal of Medical Science, ere 1854.
On Amputation.
Holmes’s System of ei or lll, ey ain: London, 1883
On Excision of the Wrist for Caries
Lancet, 1865, vol. i, pp. 308, 335, a62:
Clinical Lecture on a Case of Excision of the Knee-joint, and Horsehair as a Drain for
Wounds, with Remarks on the Teaching of Clinical Surgery, delivered at King’s College
Hospital, December I0, 1877 . :
Lancet, 1878, vol. i, p. 5.
An Address on the Treatment of Fracture of the Patella, delivered at the First Meeting of the
Session (1883) of the Medical Society of London
British Medical Journal, 1883, vol. ii, p. 855.
Remarks on the Treatment of Fractures of the Patella of Long Standing
British Medical Journal, 1908, vol. i, p. 8409.
Lancet, 1908, vol. 1, p. 1049.
PAKT V. ADDRESSES
An Introductory Lecture (on the Causation of Putrefaction and Fermentation), delivered in
the University of Edinburgh, November 8, 1869
Edinburgh, 1869 (Pamphlet).
On the Interdependence of Science and the Healing Art, being the Presidential Address to the
British Association for the Advancement of Science, Liverpool, 1896
Report of the Association.
The Third Huxley Lecture, delivered before the Medical School of Charing Cross Hospital,
on October 2, 1900. (Revised 1907) : : : : : : ;
Obituary Notice of the late Joseph Jackson Lister, F.R.S., Z.S., with special Reference to his
Labours in the Improvement of the Achromatic Microscope, contributed in a Letter to the
President of the Royal Microscopical Society
Monthly Macroscopical Journal, March 1, 1870.
INDEX
Vii
477
459
tn
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PORTRAIT OF LORD LISTER, from a photograph taken in 1895 . ; Frontispiece
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PART III
THE ANTISEPTIC SYSTEM
ON A NEW METHOD OF TREATING COMPOUND
FRACTURE, ABSCESS, ETC.
WITH OBSERVATIONS ON THE CONDITIONS OF SUPPURATION
[Lancet, 1867, vol. i, pp. 326, 357, 387, 507; vol. ii, p. 95.]
ON COMPOUND FRACTURE
THE frequency of disastrous consequences in compound fracture, contrasted
with the complete immunity from danger to life or limb in simple fracture, is
one of the most striking as well as melancholy facts in surgical practice.
If we inquire how it is that an external wound communicating with the
seat of fracture leads to such grave results, we cannot but conclude that it is by
inducing, through access of the atmosphere, decomposition of the blood which is
effused in greater or less amount around the fragments and among the interstices
of the tissues, and, losing by putrefaction its natural bland character, and as-
suming the properties of an acrid irritant, occasions both local and general
disturbance.
We know that blood kept exposed to the air at the temperature of the
body, in a vessel of glass or other material chemically inert, soon decomposes ;
and there is no reason to suppose that the living tissues surrounding a mass ol
extravasated blood could preserve it from being affected in a similar manne!
by the atmosphere. On the contrary, it may be ascertained as a matter of
observation that, in a compound fracture, twenty-four hours after the accident
the coloured serum which oozes from the wound is already distinctly tainted
with the odour of decomposition, and during the next two or three days, before
suppuration has set in, the smell of the effused fluids becomes more and more
offensive.
This state of things is enough to account for all the bad consequences of
the injury.
The pernicious influence of decomposing animal matter upon the tissues
LISTER II B
y
2 ON A NEW METHOD OF TREATING
has probably been underrated, in consequence of the healthy state in which
granulating sores remain in spite of a very offensive condition of their discharges.
To argue from this, however, that fetid material would be innocuous in a recent
wound would be to make a great mistake. The granulations being composed
of an imperfect form of tissue, insensible and indisposed to absorption, but
with remarkably active cell-development, and perpetually renovated as fast as
it is destroyed at the surface, form a most admirable protective layer, or living
plaster. But before a raw surface has granulated, an acrid discharge acts with
unrestrained effect upon it, exciting the sensory nerves, and causing through
them both local inflammation and general fever, and also producing by its
caustic action a greater or less extent of sloughs, which must be thrown off by
a corresponding suppuration, while there is at the same time a risk of absorption
of the poisonous fluids into the circulation.
This view of the cause of the mischief in compound fracture is strikingly
corroborated by cases in which the external wound is very small. Here, if the
coagulum at the orifice is allowed to dry and form a crust, as was advised by
John Hunter,’ all bad consequences are probably averted, and, the air being
excluded, the blood beneath becomes organized and absorbed, exactly as in
a simple fracture. But if any accidental circumstance interferes with the
satisfactory formation of the scab, the smallness of the wound, instead of being
an advantage, is apt to prove injurious, because, while decomposition is per-
mitted, the due escape of foul discharges is prevented. Indeed, so impressed
are some surgeons with the evil which may result from this latter cause, that,
deviating from the excellent Hunterian practice, they enlarge the orifice with
the knife in the first instance and apply fomentations, in order to mitigate the
suppuration which they render inevitable.
Turning now to the question how the atmosphere produces decomposition
of organic substances, we find that a flood of light has been thrown upon this
most important subject by the philosophic researches of M. Pasteur, who has
demonstrated by thoroughly convincing evidence that it is not to its oxygen
or to any of its gaseous constituents that the air owes this property, but to
minute particles suspended in it, which are the germs of various low forms of
life, long since revealed by the microscope, and regarded as merely accidental
concomitants of putrescence, but now shown by Pasteur to be its essential
cause, resolving the complex organic compounds into substances of simpler
chemical constitution, just as the yeast plant converts sugar into alcohol and
carbonic acid.
A beautiful illustration of this doctrine seems to me to be presented in sur-
* See Works of J. Hunter, edited by Palmer, vol. i, Pp. 429.
COMPOUND FRACTURE, ABSCESS, ETC. 3
gery by pneumothorax with emphysema, resulting from puncture of the lung
by a fractured rib. Here, though atmospheric air is perpetually introduced
into the pleura in great abundance, no mflammatory disturbance supervenes ;
whereas an external wound penetrating the chest, if it remains open, infallibly
causes dangerous suppurative pleurisy. In the latter case the blood and serum
poured out into the pleural cavity, as an immediate consequence of the injury,
are decomposed by the germs that enter with the air, and then operate as a
powerful irritant upon the serous membrane. But in case of puncture of the
lung without external wound, the atmospheric gases are filtered of the causes
of decomposition before they enter the pleura, by passing through the bronchial
tubes, which, by their small size, their tortuous course, their mucous secretion,
and ciliated epithelial lining, seem to be specially designed to arrest all solid
particles in the air inhaled. Consequently the effused fluids retain their original
characters unimpaired, and are speedily absorbed by the unirritated pleura.
Applying these principles to the treatment of compound fracture, bearing
in mind that it is from the vitality of the atmospheric particles that all the
mischief arises, it appears that all that is requisite is to dress the wound with
some material capable of killing these septic germs, provided that any substance
can be found reliable for this purpose, yet not too potent as a caustic.
In the course of the year 1864 I was much struck with an account of the
remarkable effects produced by carbolic acid upon the sewage of the town of
Carlisle, the admixture of a very small proportion not only preventing all odour
from the lands irrigated with the refuse material, but, as it was stated, destroying
the entozoa which usually infest cattle fed upon such pastures.
My attention having for several years been much directed to the subject
of suppuration, more especially in its relation to decomposition, I saw that such
a powerful antiseptic was peculiarly adapted for experiments with a view to
elucidating that subject, and while I was engaged in the investigation the
applicability of carbolic acid for the treatment of compound fracture naturally
occurred to me.
My first attempt of this kind was made in the Glasgow Royal Infirmary in
March 186s, in a case of compound fracture of the leg. It proved unsuccessful,
in consequence, as I now believe, of improper management; but subsequent
trials have more than realized my most sanguine anticipations.
Carbolic acid! proved in various ways well adapted for the purpose. It
1 Carbolic acid is found in the shops in two forms—the glacial or crystalline, solid at ordinary
temperatures of the atmosphere ; and the fluid, which sometimes passes under the name of German
creosote. The fluid variety is sold in various degrees of purity. The crude forms are objectionable
from their offensive odour; but the properly rectified product is almost fragrant. Different samples,
however, differ much in energy of action, and hence, though I have hitherto employed the liquid
B2
4 ON A NEW METHOD OF TREATING
exercises a local sedative influence upon the sensory nerves; and hence is not
only almost painless in its immediate action on a raw surface, but speedily
renders a wound previously painful entirely free from uneasiness. | When
employed in compound fracture its caustic properties are mitigated so as to
be unobjectionable by admixture with the blood, with which it forms a tena-
cious mass that hardens into a dense crust, which long retains its antiseptic
virtue, and has also other advantages, as will appear from the following cases,
which I will relate in the order of their occurrence, premising that, as the treat-
ment has been gradually improved, the earlier ones are not to be taken as
patterns.
CASE I1.—James G——, aged eleven years, was admitted into the Glasgow
Royal Infirmary on the 12th of August, 1865, with compound fracture of the left
leg, caused by the wheel of an empty cart passing over the limb a little below
its middle. The wound, which was about an inch and a half long, and three-
quarters of an inch broad, was close to, but not exactly over, the line of fracture
of the tibia. A probe, however, could be passed beneath the integument over
the seat of fracture and for some inches beyond it. Very little blood had been
extravasated into the tissues.
My house surgeon, Dr. Macfee, acting under my instructions, laid a piece
of lint dipped in liquid carbolic acid upon the wound, and applied lateral paste-
board splints padded with cotton wool, the limb resting on its outer side, with
the knee bent. It was left undisturbed for four days, when, the boy com-
plaining of some uneasiness, I removed the inner splint and examined the wound.
It showed no signs of suppuration, but the skin in its immediate vicinity had
a slight blush of redness. I now dressed the sore with lint soaked with water
having a small proportion of carbolic acid diffused through it; and this was
continued for five days, during which the uneasiness and the redness of the
skin disappeared, the sore meanwhile furnishing no pus, although some super-
ficial sloughs caused by the acid were separating. But the epidermis being
excoriated by this dressing, I substituted for it a solution of one part of carbolic
acid in from ten to twenty parts of olive oil, which was used for four days, during
which a small amount of imperfect pus was produced from the surface of the
sore, but not a drop appeared from beneath the skin. It was now clear that
there was no longer any danger of deep-seated suppuration, and simple water
dressing was employed. Cicatrization proceeded just as in an ordinary granu-
kind in compound fracture, 1t would probably be better to use the crystallized form, melting it by
placing the vessel containing it in warm water for a few minutes. Carbolic acid is almost absolutely
insoluble in water, but dissolves readily in various organic liquids, such as the common fixed oils
or glycerine.
COMPOUND FRACTURE, ABSCESS, ETC. 5
lating sore. At the expiration of six weeks I examined the condition of the
bones, and, finding them firmly united, discarded the splints; and two days
later the sore was entirely healed, so that the cure could not be said to have been
at all retarded by the circumstance of the fracture being compound.
This, no doubt, was a favourable case, and might have done well under
ordinary treatment. But the remarkable retardation of suppuration, and the
immediate conversion of the compound fracture into a simple fracture with
‘a superficial sore, were most encouraging facts.
CASE 2.—Patrick F——, a healthy labourer, aged thirty-two, had his right
tibia broken on the afternoon of the 11th of September, 1865, by a horse kicking
him with its full force over the anterior edge of the bone about its middle. He
was at once taken to the infirmary, where Mr. Miller, the house surgeon in
charge, found a wound measuring about an inch by a quarter of an inch, from
which blood was welling profusely.
He put up the fracture in pasteboard splints, leaving the wound exposed
between their anterior edges, and dressing it with a piece of lint dipped in
carbolic acid, large enough to overlap the sound skin about a quarter of an
inch in every direction. In the evening he changed the lint for another piece,
also dipped in carbolic acid, and covered this with oiled paper. I saw the
patient next day, and advised the daily application of a bit of lint soaked in
carbolic acid over the oiled paper; and this was done for the next five days.
On the second day there was an oozing of red fluid from beneath the dressing,
but by the third day this had ceased entirely. On the fourth day, when, under
ordinary circumstances, suppuration would have made its appearance, the skin
had a nearly natural aspect, and there was no increase of swelling, while the
uneasiness he had previously felt was almost entirely absent. His pulse was 64,
and his appetite improving. On the seventh day, though his general condition
was all that could be wished, he complained again of some uneasiness, and the
skin about the still adherent crust of blood, carbolic acid, and lint was found
to be vesicated, apparently in consequence of the irritation of the carbolic acid.
From the seventh day the crust was left untouched till the eleventh day, when
I removed it, disclosing a concave surface destitute of granulations, and free
from suppuration. Water dressing was now applied, and by the sixteenth day
the entire sore, with the exception of one small spot where the bone was bare,
presented a healthy granulating aspect, the formation of pus being limited to
the surface of the granulations.
I now had occasion to leave Glasgow for some weeks, and did so feeling
1 A cheap substitute for oiled silk, devised by the late Dr. M’Ghee, of the Glasgow Infirmary, and
very useful for covering poultices, &c.
6 ON A NEW METHOD OF TREATING
that the cure was assured. On my return, however, I was deeply mortified
to learn that hospital gangrene attacked the sore soon after I went away, and
made such havoc that amputation became necessary.
While I could not but feel that this case, by its unfortunate issue, might
lose much of its value in the minds of others, yet to myself it was perfectly
conclusive of the efficacy of carbolic acid for the object in view. At the same
time it suggested some improvement in matters of detail. It showed that the
acid may give rise to a serous exudation apt to irritate by its accumulation,
and therefore that a warm and moist application would be advantageous to
soothe the part, and also ensure the free exit of such exuded fluid. At the
same time it appeared desirable to protect the crust with something that would
retain the volatile organic acid more effectually than oiled silk or gutta-percha,
through which it makes its way with the utmost facility. For this purpose
a metallic covering naturally suggested itself, and as ordinary tin-foil is unsuit-
able from its porosity, I employed thin sheet-lead, and afterwards block-tin,
such as is used for covering the jars of anatomical preparations, superior to
lead on account of the facility with which it can be moulded to any shape that
is desired.
For a long time, however, I had no opportunity of giving this improvement
a trial, the compound fractures admitted into my wards during the next eight
months being merely two cases with small wounds. One of these was a fracture
of the ulna into the elbow-joint in a woman so old that suppuration, had it
occurred, would probably have proved fatal. The orifice in the integument
was extremely small, and all would most likely have gone on well had the bit
of dry lint applied to check the free bleeding from the interior been left undis-
turbed, instead of being saturated with carbolic acid as it was. This, however,
could not but be an additional safeguard, and at the same time it was satis-
factory to find that the caustic application did not interfere with the usual
healing by scabbing, cicatrization being found complete when the crust was
removed.
The other case was a fracture of the humerus a little above the elbow in a
young man, caused by a fall from a height of thirty-five feet, the wound, which
was not quite half an inch in length, being situated at the inner side of the limb,
where it must necessarily be covered by a splint. Dr. Watson, then my house
surgeon, applied lint dipped in carbolic acid covered with a slightly concave
piece of sheet-lead about as large as a shilling, and put up the limb in pasteboard
padded with cotton. At the end of ten days the inner side of the limb was
uncovered for the first time, and merely as a matter of curiosity, when the lead,
with the lint adhering to it, dropped off, disclosing a small superficial granulating
COMPOUND FRACTURE, ABSCESS, ETC. 7
sore without the slightest suppuration, just as in ordinary healing by scabbing.
This case is interesting, not so much because the compound fracture was con-
verted into a simple one, for this might have occurred under ordinary treatment,
but because it showed that in any case of fracture complicated with a small
wound, we have in carbolic acid a means which enables us to disregard the
wound altogether after the splints have been applied, instead of being under the
necessity of daily disturbing the apparatus to change the dressing.
At length a case presented itself well calculated to test the value of carbolic
acid in compound fracture.
CAsE 3.—John H , aged twenty-one, a moulder in an iron foundry, was
admitted on the rgth of May, 1866, with compound fracture of the left leg, pro-
duced in the following manner. He was superintending the raising by crane of an
iron box containing sand ready for a casting, the box and its contents weighing
about 12 cwt., when one of the chains by which it was suspended slipped, and
the box fell from the height of four feet with unbroken force upon the inner
side of his leg, which was planted obliquely beneath it. Both bones were
fractured, the tibia about its middle, and a wound an inch and a half in length,
and three-quarters of an inch broad, was made at the inner aspect of the limb,
on a level with the fracture of the tibia, and obviously communicating with it.
At the same time the soft parts generally were much contused, as was evident
from the great distension of the limb with extravasated blood. Dr. A. Cameron,
my house surgeon, finding, on manipulating the limb, that bubbles escaped
along with the blood, implying that air had been introduced during the move-
ments of the leg as the patient was being carried to the infirmary, thought it
best that I should see the case, which I did at three p.m., three hours and a half
after the accident. In order to expel the air I squeezed out as much as I could
of the clotted and fluid blood which lay accumulated beneath the skin, and
then applied a bit of lint dipped in carbolic acid slightly larger than the wound,
and over this a piece of sheet-tin about four inches square. Finally the limb
was placed in pasteboard splints, resting on its outer side with the knee bent.
At eight p.m. some more acid was added with another piece of lint, so that
the crust of clots, carbolic acid, and lint was about one-third of an inch in thick-
ness. A hot fomentation also was applied over the inner aspect of the leg, the
crust being protected by the tin. Next day he was pretty easy, and had passed
a quiet night, though occasionally awakened by starting pains ; the pulse was go,
but he took some food with relish. The surface of the crust was touched again
with carbolic acid, and the fomentation was continued, and in place of the
internal pasteboard splint, a large sheet of tin was applied over the flannel
8 ON A NEW METHOD OF TREATING
from the knee to the ankle, being retained in position by looped bandages.
This proved a very satisfactory arrangement, the tin having sufficient firmness
to answer the purpose of a splint, while it most effectually retained the moisture
of the flannel, which, again, served as an excellent padding. The fomentation
was changed night and morning, and gave great comfort to the patient, and
once a day carbolic acid was applied lightly to the crust.
Two days after the accident the limb was easier, but the circumferential
measurement of the calf continued the same, and the pulse was 96, though soft.
On the fourth day—the critical period with reference to suppuration—the limb
was free from pain, and the calf less tense, and distinctly reduced in dimensions ;
while the pulse had fallen to 80, and the patient had enjoyed his food after
a good night’s rest. After this the swelling steadily subsided, the skin remain-
ing, as it had been from the first, free from the slightest inflammatory blush,
and his general health was in all respects satisfactory. Seven days after the
receipt of the injury there was some puriform discharge from the surface of the
skin where the carbolic acid, confined by the smaller piece of tin that covered
the crust, had produced excoriation by its caustic action ; and to prevent need-
less irritation from this cause, the tin was reduced so as to leave only a narrow
flat rim round a bulging part which corresponded to the crust.
About a fortnight after the accident a sense of fluctuation was experienced
over the seat of fracture, but, as all was going on favourably otherwise, I hoped
that this was due simply to serum from the effused blood; and in a few days
it had completely disappeared, not a drop of pus meanwhile having escaped
from beneath the crust. About this time the edges of the crust became softened
by the superficial discharge from the surrounding parts, and these softened
portions were daily clipped away with scissors. Thus the circumferential part of
the crust which had overlapped the skin was removed, and that which lay over the
extravasated blood in the wound was also reduced to smaller and smaller size.
On the 7th of June, nearly three weeks after the accident, an observation
of much interest was made. I was detaching a portion of the adherent crust
from the surface of the vascular structure into which the extravasated blood
beneath had been converted by the process of organization, when I exposed
a little spherical cavity about as big as a pea, containing brown serum, forming
a sort of pocket in the living tissues, which, when scraped with the edge of
a knife, bled even at the very margin of the cavity. This appearance showed
that the deeper portions of the crust itself had been converted into living tissue.
For cavities formed during the process of aggregation, like those with clear
liquid contents in a Gruyére cheese, occur in the grumous mass which results
from the action of carbolic acid upon blood; and that which I had exposed
COMPOUND FRACTURE, ABSCESS, ETC. 9
had evidently been one of these, though its walls were now alive and vascular.
Thus the blood which had been acted upon by carbolic acid, though greatly
altered in physical characters, and doubtless chemically also, had not been
rendered unsuitable for serving as pabulum for the growing elements of new
tissue in its vicinity. The knowledge of this fact is of importance ; as it shows
that, should circumstances appear to demand it, we may introduce carbolic
acid deeply among the blood extravasated in a limb, confident that all will
nevertheless be removed by absorption. A few days later all traces of the little
cavity had become obliterated by the granulating process.
At the close of the third week the application of carbolic acid to the crust
was discontinued, and the original internal pasteboard splint padded with
cotton was again employed, instead of the tin and fomentation. What remained
of the crust was still kept protected with the tin cap, with the view of ascer-
taining how long it would continue to adhere; and at length, nearly four weeks
after the accident, I tore it off from the vascular surface beneath, which bled
as I did so. The crust had preserved the subjacent parts from disturbance as
effectually as if it had been a piece of living integument; and it is worthy of
remark that the vascular surface below had not the pulpy softness of granu-
lations, but was comparatively firm and substantial. The bit of crust still
smelt of carbolic acid, though none had been applied for five days.
At the expiration of six weeks from the receipt of the injury the fragments
were found firmly united in good position, just as if the fracture had been
a simple one, though the cicatrization of the rather extensive sore was not
complete till a later period. |
CASE 4.—James W , aged ten, was engaged in a turner’s factory worked
by steam power on the 8th of June, 1866, when his right arm was drawn in
between a strap and a shaft turned by it. He called out for assistance, but
thinks two minutes must have elapsed before the machinery was stopped, and
during the whole of this time the strap, which was still moving while he held
the arm steady, was cutting into the ulnar side of the forearm, breaking through
the ulna about its middle, while the radius was bent with ‘ green-stick ’ fracture.
He was taken at once to the infirmary, where the wound was found to be about
an inch and a half in depth, occupying more than half the circumference of
the limb, chiefly at the dorsal aspect, but extending round also to the palmar
side. The upper fragment of the ulna was protruding about an inch, and two
strips of muscle, about a quarter of an inch in thickness and from two to three
inches in length, were hanging out ; the lacerated state of the parts confirming
the boy’s account of the accident.
Io ON A NEW METHOD OF TREATING
On seeing him about two hours afterwards, I sawed off the protruding
portion of the ulna, and the tags of muscle having been previously clipped away,
I applied carbolic acid freely to the whole interior of the wound, including the
exposed surface of the bone; and having straightened the radius, which gave
way during the process, placed the limb upon a wooden palmar splint. Avoiding
any attempt to approximate the lips of the wound, I covered it with a piece
of sheet-tin, sufficiently large to overlap the sound skin about a quarter of an
inch in every direction. The limb was fixed to the splint by a bandage, so
arranged as to permit the removal of the tin without disturbing the apparatus ;
and hot fomentations were applied over the whole. A few minutes after the
carbolic acid was applied he said he was perfectly easy. At seven o'clock he
asked for food, and took it. His pulse was then 84. At eight p.m. I saw him
again, and applied beneath the tin a piece of lint dipped in carbolic acid, about
as large as the wound. Noticing some distortion in the upper arm, I found
that the humerus also was broken in its lower third, and applied splints accord-
ingly, the limb being kept supported upon a pillow beside him. He slept a
good deal during the night, though moaning and starting occasionally. Next
day his pulse was 108 ; but he took his breakfast heartily, and the tongue was
healthy, while he complained only of a little uneasiness about the elbow, and
even this disappeared on changing the fomentation cloth. A piece of sheet-tin
was now arranged so as to form a sort of cover for the forearm, including the
hand. Being retained in position by looped bandages, it increased the steadi-
ness of the limb, while it ensured efficiency of the fomentation.
Two days after the accident the oozing of blood and serum, which had
been considerable during the previous twenty-four hours, had nearly ceased ;
but he still experienced comfort from the fomentation, though any pain which
he felt was connected with the simple fracture of the humerus. His pulse
was 88; his tongue clean and appetite good after a sound sleep at night; and
from this time onward his general health continued perfectly satisfactory.
On the fourth day a small quantity of pale, grey, slimy discharge was observed
from beneath the crust at one part; and thinking that this might, perhaps,
have occurred for want of proper action of the carbolic acid, I applied the latter
with unusual freedom to the surface of the crust. This was repeated at night ;
and the same energetic use of the carbolic acid, twice in the twenty-four hours,
was continued on the fifth day. Yet, on the sixth day, the discharge from
beneath the crust, instead of being diminished, was increased, and more puri-
form to the naked eye ; while, under the microscope, there was clear indication
of new cell-formation, whereas, on the day before, nothing but fibrinous material,
with granular and other débris, had been discoverable. On the seventh day
COMPOUND FRACTURE, ABSCESS, ETC. II
the discharge was still greater in amount; yet the limb remained free from
pain, and was steadily diminishing in circumference, and pressure in the neigh-
bourhood of the crust failed to induce any increase of the discharge, which
appeared to be merely superficial.
In the course of the next few days it became apparent that this discharge,
so far from being the result of insufficient action of the carbolic acid, was caused
by the stimulating influence of the acid itself, applied with greater freedom
over a crust much thinner than that of Case 3. Suppuration from this cause
is, however, productive of no mischief, as will be better understood from the
sequel. That such was the case in this instance was manifest on the fourteenth
day, when the crust, which was nearly detached, was removed, disclosing an
appearance for which I confess I had not been prepared. In place of the deep
and ragged wound was a granulating sore, nearly on a level with the skin, and
pretty uniform in surface, except at one part about its middle, where there was
a depression about half an inch in depth, at the bottom of which a small portion
of the outer surface of the ulna was visible, bare, but of pink colour. Not only
had the compound of blood and carbolic acid which had existed in the depths
of the wound been organized, but the portions of tissue killed by the violence
to which they had been subjected in the accident, and also those destroyed
by the caustic action of the carbolic acid, had been similarly acted on, and all
had been, so to speak, fused together into a living mass, without the occurrence
of any deep-seated suppuration. .
By the nineteenth day the exposed part of the bone was covered, and the
depression in the sore obliterated by granulation, without any exfoliation
occurring ; and two days short of seven weeks after the accident the sore was
entirely healed.
The extensive loss both of bone and of the soft parts made osseous union
of the ulna a matter of difficulty, and on the 5th of August the limb was placed
in a starched apparatus, to promote complete consolidation, and he was soon
after discharged from the hospital.
About six weeks later he presented himself at the infirmary, and the bandage
was removed in my absence, when, the bone appearing firm, he was allowed
to dispense with the apparatus, and was unfortunately not directed to show
himself again. In the course of a few weeks, however, he appeared with the
fragments again movable. The starched bandage was therefore reapplied, but
when I last saw him, some weeks ago, bony union had not yet occurred. A
good deal of osseous formation had, however, taken place, so that the fragments
now overlapped each other; and should the cure be still incomplete when he
next shows himself, the case will-be a fair subject for Bickersteth’s method of
12 ON A NEW METHOD. OF TREATING
treating ununited fracture by drilling. Meanwhile, the radius being firm, and
the injured extensors of the fingers having completely regained their powers,
he will, in any event, have a very useful hand.
This case indicated a greater range of applicability of the treatment by
carbolic acid than I had anticipated, and encouraged me to employ it under
the almost desperate circumstances of the following case.
CASE 5.—Charles F——, a fine, intelligent boy, seven years of age, was
knocked down at eight p.m. on the 23rd of June, 1866, by an omnibus crowded
with passengers inside and out, and one if not both wheels passed over his right
leg, breaking both the bones and inflicting a frightfully extensive wound. The
person who brought him to the infirmary said that he had lost a great deal of
blood, and the presence of a compress in the ham, placed there by the medical
man who saw him at the time of the accident, corroborated this statement.
When I saw the child, after an unavoidable delay of three hours, he was greatly
prostrated by shock as well as haemorrhage, so much so that amputation appeared
likely to afford but a slender chance of life, although the state of the injured
parts seemed at first sight to admit of no alternative. The tibia, which was
broken about its middle, lay exposed in a wound occupying almost the entire
length and breadth of the inner aspect of the leg, reaching from the inner condyle
of the femur to within an inch and a quarter of the tip of the internal malleolus ;
the skin having been stripped back so as to lay bare the gastrocnemius as well
as the bone. The large flap of integument was perforated about two inches
from its edge opposite to the seat of fracture, and there was also an opening
in the skin on the outer side of the leg, implying that the violence had acted
with full effect upon the whole thickness of the limb. Yet the bone was not
comminuted, and the muscles, though evidently severely contused, were not
much lacerated, while the anterior tibial artery was felt beating in the foot ;
and, hopeless as would have been the idea of trying to save the limb by ordinary
treatment, I determined to make the attempt by the help of carbolic acid.
Chloroform having been administered, the acid of full strength was applied
with great freedom, the contused mass being repeatedly squeezed, to induce
the liquid to insinuate itself into all its interstices, including that between the
riding fragments of the tibia. The flap of skin was then brought towards its
natural position, and lint soaked in the acid was placed upon the wide raw
surface which still remained exposed, and over the lint a piece of sheet-tin.
The other openings in the integument were similarly treated; and, the riding
of the fragments having been corrected by extension, the limb was laid on its
outer side, with the knee bent, upon an external pasteboard splint, moulded
COMPOUND FRACTURE, ABSCESS, ETC. 13
to the leg and foot, and strengthened by a temporary wooden splint. A porous
cloth was applied over the tin to absorb the blood and serum which must escape
from beneath its edges; and the whole apparatus was secured with a roller.
At the conclusion of the dressing the pulse was 112.
He passed a restless night, though occasionally dozing, and the pulse next
morning was 120. The bandage having been cut away sufficiently to enable the
tin to be removed, the wound was found to have gaped so that the lint no longer
covered the whole of it. Pieces of the cloth, which had become soaked with the
exuded blood, were placed upon the exposed part, and also over the lint so as
to make the crust more substantial, and the whole was freely treated with
carbolic acid. The tin was then bulged out so as to be accommodated to the
thickened crust, while overlapping the neighbouring skin to a slight extent ;
being retained in position by a couple of turns of bandage. A hot fomentation
was then placed upon the inner aspect of the limb, and the whole leg enveloped
in a large sheet of block-tin secured by looped bandages.
In the evening the pulse was 136, and on the following morning, thirty-six
hours after the accident, it had risen to 168, and was very weak. He lay talking
to himself in a rambling manner, unable to understand what was said to him.
He was extremely restless, and had taken no food whatever since his admission.
During the next night, however, he became composed, and took a little milk ;
and on the morning of the third day he was found to be again intelligent, while
the pulse had fallen to 140, and was of fair strength. The skin in the vicinity
of the injury, both at the knee and ankle, was free from discoloration or
swelling ; but part of the large flap of skin over the calf was of purple tint, and
had evidently lostits vitality. This dead part was touched with carbolic acid,
to preserve it from decomposition, and convert it into a crust for the protection
of the subjacent textures, and an additional piece of tin was applied to cover it.
A good deal of brown transparent fluid escaped from beneath the crust.
On the fourth day the pulse was 120; he was quite bright and tranquil,
and said he felt no pain. There was still no odour about the injured part,
except that of carbolic acid. The discharge was much diminished, and was
principally serous.
By the sixth day the pulse was as low as 108. He had a hearty appetite,
and also took with avidity the six ounces of port wine allowed him during the
twenty-four hours. His tongue, which had previously been dry, was moist.
He had slept well at night, though waking occasionally with a scream. The
discharge from beneath the crust, trifling in amount, was chiefly serous.
On the eighth day the splint was removed for the first time, and was covered
with sheet-tin in order to prevent the discharge from softening the pasteboard.
14 ON A NEW METHOD OF TREATING
The leg had become slightly bent inwards through the yielding of the splint ;
and when it was now straightened, the upper margin of the crust became
detached, exposing a deep granulating cavity. A bit of lint, dipped in carbolic
acid, was applied lightly over this opening, and the tin was readjusted so as
to cover it. Pressure in the neighbourhood of the injured part, about the knee,
ankle, and calf, failed to induce the slightest increase of the discharge, which
was thus shown to come merely from the surface beneath the crust, and was
still for the most part transparent.
At the close of the second week his state was on the whole very favourable.
His general health was much improved; and although he still suffered occa-
sionally, especially at night, from restless movements of the limb, these had been
much restrained by a new splint, extending from half-way up the thigh to the
toes. The wound was certainly very large, measuring eight inches in length
by six in greatest width ; but it was healing round almost the entire circum-
ference. In order to permit cicatrization, which carbolic acid tends to check,
the detached edges of the crust had been clipped away, and the exposed narrow
ring of granulations was dressed with lint dipped in a solution of sulphite of
potash—five grains to an ounce of water. The crust, however, was still touched
daily as before with carbolic acid, while the tin still covered the whole of the
injured part. By this means it was intended that cicatrization should be
allowed to go on, and yet decomposition of the discharge be prevented ; and
this seemed to be to a great extent, if not entirely, attained.
There was, however, one unfavourable circumstance. The little sore on
the outer side of the leg, which had been dressed separately without carbolic
acid, and had for some time been observed to be increasing rather than diminish-
ing, now assumed unmistakably the appearance of a mild form of hospital
gangrene, and became blended with the main sore. For two days an attempt
was made to correct the disease by touching the affected part with nitric acid ;
but on the eighteenth day it was clear that some more effectual measures must
be adopted, as the skin in the vicinity had become insidiously undermined to
a very serious extent. Accordingly I placed the boy under chloroform, and
scraped away with a spoon all the soft grey sloughs, slitting up the skin in order
to gain access to them, and in some parts clipping portions of it away, and
then applied the strongest nitric acid thoroughly to the bleeding surface. As
the disease extended up to the anterior edge of the crust, I thought it right to
examine the state of the parts beneath, and as it was pretty loose I removed it.
And now a sight presented itself which filled me with horror. There was, indeed,
no appearance of hospital gangrene in the parts which the crust had covered,
the granulations there having the florid aspect of perfect health; but in the
COMPOUND FRACTURE, ABSCESS, ETC. 15
large sore lay the lower fragment of the tibia, freely exposed to the extent of
two inches and a half in length, bare and white like a macerated bone. At the
upper end of this fragment, and apparently for a considerable distance from it,
the bone was thus denuded round its entire circumference ; and, judging from
previous experience, there was reason to expect that, even if the patient should
survive the profuse suppuration which was to be anticipated, about two inches
of the whole thickness of the tibia must exfoliate, an amount of loss which
in the child’s small limb, would of necessity render it utterly useless. The
upper fragment was also bare for about half an inch just above its extremity,
but the end itself was covered with prominent granulations.
Though despairing of any good result, I resolved to watch for a while the
progress of events, prepared to amputate as soon as the boy’s health should
show signs of failing; and comforting myself with the reflection that he had
been brought into a state greatly more favourable for the operation than on
his admission. In order to keep down the amount of the discharge the sore
was dressed with the sulphite-of-potash lotion, a poultice being applied to the
part which had been treated with nitric acid. When the sloughs caused by the
caustic separated a healthy surface appeared, which in the course of the next
ten days was nearly healed. In other parts of the sore, however, grey patches
occasionally showed themselves, assuming healthy characters after being touched
with carbolic acid, which, when efficient, has the advantage over other caustics
of being painless. But at length spots of hospital gangrene appeared in a form
no longer amenable to this mild treatment, in spite of which they began to
extend rapidly, and on the 26th of July it became necessary to put the child
again under chloroform and apply nitric acid in the same thorough manner as
before. This had the effect of producing a perfectly healthy state of the whole
sore, which proceeded to heal with great rapidity ; so that by the 8th of August
it was found to measure an inch less in length and two inches less in greatest
breadth than at the time when the crust was removed.
In the meantime his general health, instead of deteriorating, had improved,
and he was evidently regaining flesh, while the discharge of pus was astonish-
ingly little considering the state of the limb, being barely sufficient to soak the
single layer of lint that covered the sore.
The explanation of this satisfactory state of things was afforded by an
observation of much interest made at this period. Since the removal of the crust
the granulations had been growing up on all sides about the bone, so that the
bare part of the upper fragment was almost entirely covered in, and even the
lower fragment, which projected beyond the level of the upper, was to a great
extent embedded in the new growth. It had been noticed before the end of
16 ON A NEW METHOD OF TREATING
this fragment was so much covered up, that granulations were sprouting from
the medullary canal, showing that the bone was not dead in its entire thickness.
Nevertheless, as the superficial parts had certainly lost their vitality, I had not
doubted that a thin layer at least must exfoliate from the whole. Now, how-
ever, I observed that some of the surface which remained exposed had assumed
a pink colour, implying that the layer of dead bone, whatever its thickness
might have originally been, had become so thin as to be transparent, through
absorption by new tissue growing in the interior. Further, on attempting to
pass the eyed end of a probe between the tibia and the granulations which had
enveloped it, I found to my surprise that the instrument could only be intro-
duced for a very short distance, the granulations, with the exception of a narrow
free border, being everywhere adherent. The new tissue outside the bone
had coalesced with that within, after complete absorption of the intervening
dead stratum. Hence the remarkable absence of discharge from around the
bone.
During the following month I was absent from home, but was informed
that the same process was for some time continued: the granulations gradually
encroaching more and more on the exposed bone, and adhering to it as they
advanced. The upper fragment was thus entirely covered without any exfolia-
tion occurring, and the bare surface of the lower fragment was reduced to com-
paratively small dimensions. On the roth of September the remainder of the
dead part, being loose, was removed without difficulty as an exfoliation. It
was about an inch in greatest length; but was of extremely irregular shape,
full a quarter of the circumference of the tibia being deficient. At the upper
end, where it had been most prominent and had become discoloured, it had
nearly the full thickness of the dense tissue; but towards the lower end it
became thinned away, so as to be in some places as delicate as tissue-paper.
The outer surface presented near the margin an appearance of especial interest,
being at some parts, even where the bone had considerable thickness, variously
scooped and bevelled in a manner that admitted of no other explanation than
that the granulations overlapping the dead bone externally had been engaged
in its absorption. On applying a magnifier to these excavations in the external
surface, they were seen to present a peculiar velvety aspect, differing from the
rest of the exterior, but resembling the internal parts of the exfoliation.
The only observation at all analogous to this with which I am acquainted
is that of the effects produced upon the ivory pegs used in Dieffenbach’s method
of treating ununited fracture, the parts of the pegs driven into the bone having
been observed, when removed, to have suffered diminution in size. This has
hitherto remained as an isolated fact, and it has been regarded as an axiom in
COMPOUND FRACTURE, ABSCESS, ETC. 17
surgery that a piece of bone once dead must all come away as an exfoliation. Why
it was that in the case before us the osseous tissue destroyed by external violence,
aided by the action of carbolic acid, was so exceptionally affected by surrounding
parts, the granulations in its vicinity discharging the office of absorbents of
the dense tissue, instead of forming pus like those around an ordinary exfolia-
tion, I will reserve for future discussion, when I shall have occasion to point out
the great importance of the fact in its bearing both on pathology and practice.
Meanwhile I may remark that it illustrates beautifully the function of absorp-
tion, which, even where solid substances are taken up, does not require any
special set of absorbent vessels, but may be effected even by granulations, the
most rudimentary of all tissues, each cell feeding upon any suitable substance
in its vicinity.
We also see at once the value of the observation with reference to the treat-
ment of compound fracture with carbolic acid; for it shows that in cases in
which the bone is exposed, the acid may be applied so freely as to cause death
of its tissue without necessarily inducing exfoliation.
The case was now reduced to one of simple fracture with a large granu-
lating sore, and this was greatly diminished and healing rapidly, while the
union of the fragments was becoming very firm ; and the limb would doubtless
soon have been entirely sound had it not been for that cruel scourge, hospital
gangrene. This, however, had shown itself ten days before the removal of the
exfoliation, not in the sore, but about an inch from its edge, as a pustule in the
cicatrix, which on bursting disclosed a grey slough that soon showed its characters
unmistakably, producing considerable destruction of the scar, although the
original sore continued to heal kindly.
I will not enter into the history of this and numerous subsequent attacks
of the disease further than to state that they were partial in their effect, the
unaffected parts still healing with rapidity, and that they continued to yield
to the treatment with nitric acid; so that at one time the whole sore was very
nearly healed.
But in the early part of October the disease assumed a more intractable
form, and in spite of the most energetic use of nitric acid on several occasions,
which produced illusory appearances of temporary improvement, by the 27th
of the month the sore had become enlarged to nearly its original dimensions,
while the limb had swollen greatly through inflammation caused by the irrita-
tion, and the boy’s general health was rapidly giving way under the increased
discharge and nervous excitement.
The question of amputation now again presented itself, but a good airy
room in a different department of the hospital being happily now at my disposal,
LISTER II ©
18 ON A NEW METHOD OF TREATING
I determined to give the limb one last chance. Before he was taken to the
new ward, nitric acid was once more thoroughly applied. His nurse was directed
to change the poultice every three hours, and he continued to take wine and
some tonic medicine. His general health immediately improved, and when
the slough separated, the sore looked healthy. It was now dressed with lint
dipped in a solution of sulphate of copper, five grains to an ounce of water, and
over this a poultice, the whole being changed every three or four hours night
and day; and under this treatment cicatrization proceeded rapidly. Yet
when the scar had attained a certain width, a tendency to vesication again
showed itself, threatening recurrence of the disease, and in order to prevent
the newly formed epidermis from acquiring poisonous qualities as it seemed
to do, I ordered the lint with the lotion, as well as the poultice, to be extended
over the whole cicatrix. From the time this dressing was adopted the progress
was uninterruptedly satisfactory till the gth of January, when the sore was
at length entirely healed, and he was allowed for the first time to put his foot
to the ground. The contraction of the large cicatrix, involving at one part the
gastrocnemius muscle, had caused some bending of the knee and pointing of
the toes. The former has since become corrected spontaneously by his habitual
attitude, sitting in bed with the legs extended before him. The pointing of
the toes has also become diminished, and will probably soon pass off entirely,
without the division of the tendo Achillis, which I had in view. The tibia,
which has long been firm, is of precisely the same length as the other, and the
contour of the limb is natural. His general health also is excellent; but he
was detained in the hospital till the 9th inst. (March 1867), on account of an
obstinate eczematous eruption on the integument of the leg irritated by the
long-continued poulticing.
CasE 6.—The following case terminated fatally, but from circumstances
of an accidental nature; and I trust that the instruction to be derived from it
will not be interfered with by the unhappy ultimate result.
John C——,, aged fifty-seven, a labourer, was working in a quarry at Row,
near Helensburgh, on the Clyde, at nine a.m. on the 26th of October, 1866, when,
striking with a crowbar an overhanging part, he brought down an enormous
mass of stone weighing six or seven tons, which fell in large blocks on and about
him. His right thigh-bone was broken in its lower third, and, as afterwards
appeared, the end of the upper fragment was driven through the skin at the
inner aspect of the limb a little above the knee. The right collar-bone was
fractured at the same time, and he was severely contused in other parts. It
was long before his only companion in the quarry could extricate him from
COMPOUND FRACTURE, ABSCESS, ETC. 1g
his position, and the procuring of a conveyance involved further delay ; so that
a considerable period elapsed, during which he lost much blood from the thigh,
before he could be taken to Helensburgh. Here he was placed on a litter, with
a warm moist blanket round the limb, with the object, as he said, of checking
the bleeding, which, however, it could not but tend to encourage. He was
then conveyed by train to Glasgow, where he reached the infirmary six hours
after the occurrence of the accident.
Dr. Archibald Cameron, the house surgeon, seeing the case to be a very
grave one, at once sent for me, but without any delay introduced carbolic acid
into the wound by means of a piece of lint held in a pair of dressing forceps,
passing it about an inch in every direction beneath the integument, after squeez-
ing out a considerable quantity of extravasated blood from the orifice, which
was large enough to admit the tip of the finger.
On arriving, an hour after the patient’s admission, I found him in a state of
prostration sufficiently explained by the severity of his injuries and by the
blood lost to the circulation, including a large amount extravasated in the
limb, and distending, not only the whole thigh, but the calf, the tenseness of
which contrasted strikingly with the flaccidity of the other.
Under these circumstances decomposition of the blood effused among the
tissues would have been necessarily fatal. And yet, considering the length
of time that had elapsed since the receipt of the injury, and the fact that a
reeking flannel had been for two hours in contact with the wound, and had
already a somewhat offensive odour when removed from it, there seemed but
a poor chance for the treatment with carbolic acid. On the other hand, taking
into account the man’s time of life and general condition, I believed that to
amputate through the thigh infiltrated with blood would be certainly to kill him.
And therefore, as it was impossible to say that the other treatment had no
chance, while, if it should prove successful, it would have the immeasurable
superiority of saving limb as well as life, I determined to persevere with it.
Having removed from the wound the dressings placed on it by Dr. Cameron,
I forcibly squeezed out a further large amount of blood, and applied carbolic
acid in lint and also mixed with blood, so as to provide for a crust of considerable
thickness overlapping the skin by about half an inch every way. This was
covered with a circular piece of tin, two inches across, well bulged out except
a flat margin about a quarter of an inch wide, which rested on the surrounding
integument. This tin cap was retained in position by a single turn of bandage
tied round the limb.
The lower end of the upper fragment was much displaced downwards in
the vicinity of the wound, but returned towards its natural position on extension
C2
20 ON A NEW METHOD OF TREATING
of the limb. There still remained considerable depression anteriorly over the
seat of fracture ; but the lower fragment did not seem to project towards the
ham so much as to forbid the use of the long splint. This I accordingly employed
with two interior splints to support the muscles of the thigh, one of Gooch’s
material on the outer aspect, the other a large sheet of stout block-tin, embracing
the anterior, inner, and posterior aspects of the limb to a little below the knee,
padded in the first instance with a dry towel, for which a hot fomentation should
be substituted when all tendency to haemorrhage should have ceased. The
object of having the tin extend round the back of the thigh was that it might
prevent the discharges from soaking into the bed beneath ; and in this way it
proved extremely useful.
He passed an uneasy though not entirely sleepless night, suffering more
from his shoulder and bruised side than from the thigh. Next morning his
aspect was favourable, the pulse 76, and tongue natural; he took a little tea
for his breakfast, but nothing solid. The tin cap having been removed, care
being taken to avoid detaching the crust along with it, carbolic acid was applied
to the surface of the latter. A hot fomentation cloth was then placed on the
inner side and front of the thigh and gave him great comfort, and when the
dressing was completed he was quite easy. The interior splints being kept in
position by looped bandages, and the long splint by the usual folded sheet fixed
by pins, along with the perineal band and handkerchief round the foot, the
fomentations could be changed night and morning without any disturbance of
the limb.
The following night he had a good deal of sleep, the thigh not causing him
any inconvenience ; and next day, the third after the accident, he took solid
food with relish. His pulse was 72, and his tongue continued moist, though
he was somewhat thirsty. The crust was touched again with carbolic acid,
and covered with a circular piece of calico to prevent the tin cap from adhering
to it. He still found comfort in the fomentations.
On the fourth day he made a substantial breakfast after a good night’s
rest, and was not so thirsty. There was, however, now seen for the first time
a slight blush of redness on the front of the thigh over the seat of injury. This
was on the fifth day somewhat increased, and the thigh and calf were both
more swollen. The tongue also was slightly furred at the base, and his appetite
was not quite so good.
On the sixth day the dimensions and appearance of the limb were unaltered,
but on the seventh both the redness and swelling were distinctly diminished.
By the end of the second week his appetite was improved and his pulse
was 76; while there had not been a drop of discharge from beneath the crust,
COMPOUND FRACTURE, ABSCESS, ETC. 21
which had been still touched daily with carbolic acid, the fomentations also
having been continued. The swelling, however, had not subsided, and the
redness, though varying in extent and degree, had never disappeared from over
the seat of fracture. On the fifteenth day a defined prominence made its appear-
ance at this part in a space about as large as the palm of the hand, a little further
forward than the crust, and a sense of fluctuation was to be perceived in it.
In the evening Dr. Cameron, on changing the fomentation, saw more pus than
he thought could be accounted for by the superficial excoriation round the crust,
and next morning, on removing the flannel, I found it soaked with similar dis-
charge ; a considerable quantity also lying between the tin splint and the limb.
On raising the tin cap, the matter was seen welling out from beneath the lower
edge of the crust. It was perfectly free from odour, confirming the conclusion
I had previously arrived at that this abscess was not in any way caused by
decomposition from atmospheric influence. The long period that elapsed before
it made its appearance, together with the absence of any serious constitutional
disturbance, clearly showed that the carbolic acid had effectually answered
the purpose for which it was applied, the constant oozing of blood from the
small wound having doubtless been in the patient’s favour, by preventing
decomposition from penetrating far into the interior before he came under
treatment. We know that a mass of extravasated blood occasionally becomes
the seat of suppuration without the existence of any external wound. A curious
instance of this occurred lately in my practice, in a boy who fell down the hold
of a ship.upon his head, and, besides serious cerebral symptoms, exhibited at
once a remarkable prominence of the right eyeball, evidently due to extravasa-
tion of blood into the orbit. There being no wound, I expected that the blood
would be absorbed; but after the lapse of several days, the prominence of the
eye showed increase rather than diminution, and the boy began to complain
of supraorbital pain. Fluctuation then became perceptible, and pus was evacu-
ated by incision, after which the eyeball gradually resumed its natural position.
Such I supposed to be the nature of the abscess in C——’s case, and previous
experience made me fear that, if decomposition of its contents should occur, the
irritation of the fetid pus might cause very serious consequences from rapid
extension of suppuration among the imperfect and feeble products of the
organization of the blood in the yet swollen limb.
Hence I had intended to evacuate the matter by aid of carbolic acid in
such a way as to prevent decomposition. As the abscess was not near the
surface at the part where it appeared to be pointing, I had reckoned on having
plenty of time for my operations, and was greatly disappointed to find that it
had discharged itself spontaneously.
22 ON A NEW METHOD OF TREATING
Nevertheless, as the pus was proceeding from beneath the crust impregnated
with carbolic acid and was still quite odourless, I did not altogether despair of
attaining my object. In order to make the crust more effectual, I extended
it for about three-quarters of an inch at the part from which the pus was escap-
ing, by a piece of lint dipped in carbolic acid, which, when mixed with pus,
forms a sort of curdy mass which answered pretty well for a crust. A consider-
able quantity of matter, of moderate consistence and greenish-white colour,
was then pressed out from the limb. A new tin cap having been made, large
enough to cover the whole of the extended crust, the fomentation was continued
as usual.
Next day it was evident, from the sense of fluctuation, that reaccumulation
had occurred in the abscess, but no further discharge had taken place. On
removing the tin cap, however, pus was seen to well out from a new situation
at the upper edge of the crust. A piece of lint dipped in carbolic acid was at
once placed on this part, and the matter was pressed out and carefully collected
measuring 3 0z., of moderate consistence and yellowish-white colour, still without
odour except that of carbolic acid. The crust having been somewhat extended
at the situation of the new opening, the whole was freely treated with carbolic
acid, the tin cap readjusted, and fomentation continued.
During the rest of the week that followed the first evacuation of the abscess
the same treatment was pursued with the most satisfactory results. Some pus
was usually seen on the fomenting flannel both morning and evening, and some
was pressed out of the limb from the orifice last formed, but the amount rapidly
diminished in quantity, and also became thinner and more transparent, while it
continued free from odour. It may be worth while to mention in detail the
quantities obtained from the limb in the morning of each of these days. On
the seventeenth day it was an ounce and a half, somewhat thinner than before ;
on the eighteenth, two drachms and a half, decidedly thinner; on the nine-
teenth, half a drachm, much thinner and more transparent ; on the twentieth,
a quarter of a drachm, similar in quality; and on the twenty-first, six drops
only, and almost free from opacity. Finally, in the evening of that day no
discharge was seen on the flannel, nor could any be squeezed out from the limb.
Meanwhile the calf, which had increased markedly in circumference just before
the abscess opened, steadily diminished, and in the thigh all swelling disappeared
from over the seat of fracture, so that the end of the upper fragment, previously
quite obscured, could be distinctly defined. His general health, too, had im-
proved ; his tongue had become quite clean, and he had acquired for the first
time since his admission a genuine appetite, the pulse continuing about 72.
I suspect, however, that this success made us relax a little our vigilant
COMPOUND FRACTURE, ABSCESS, ETC. 23
care in guarding against decomposition. But be this as it may, the method
which we pursued in order to avoid it was not, as experience has since
shown, thoroughly trustworthy. Would that I had at that time known of
the mode of proceeding which will be found described in a future section
of this communication. Very different then might have been the issue of
the case !
On the twenty-second day pus was again found in the flannel, and some
bubbles of gas were observed to escape along with the two or three drops that
could be squeezed from the limb, and these had a distinctly offensive odour.
Judging it now useless to retain the crust any longer, I removed it, and found
the original wound still sealed by the original clot, the openings by which the
pus had escaped being new apertures in the skin overlapped by the crust. In
the after-part of the day he had a good deal of uneasiness, and in the evening
half an ounce of pus, with numerous air-bubbles, was pressed out of the limb
by Dr. Cameron. After this the patient passed a comfortable night, and in the
morning only two drachms of matter could be procured from the thigh, but
this was thicker and more opaque than it had been, with decidedly offensive
odour, and contained bubbles of gas; there was also pus in the flannel. There
was, further, some return of swelling over the seat of fracture.
But though the plan of dealing with the abscess had failed to accomplish
all that I desired, its essential object appeared to have been attained. For
during the week in which decomposition was prevented, the thigh had become
so much consolidated and strengthened that all danger of serious consequences
seemed to have been tided over. No extension of the suppuration took place
beyond the trifling degree above described, and his constitution did not suffer.
Any further use of carbolic acid being obviously uncalled for, the sore was
simply dressed with a lotion, the lint being so arranged as to allow free escape
for the pus, and afterwards, to promote this more effectually, a small perforated
caoutchouc tube was introduced, a dry cloth being substituted for the fomenta-
tion. Under this management the discharge gradually diminished in quantity,
and became again thinner and more transparent, and the swelling of the calt
became steadily reduced.
Still the opening did not close, and on the 2nd of December, more than
a fortnight having passed in this way, I introduced a probe, and found that it
passed downwards to bare bone, including a considerable extent of surface in the
lower fragment. Here, then, was presented the prospect of a tedious process
of exfoliation ; whereas if decomposition of the pus had not occurred, the granu-
lations would probably have closed upon the dead bone, and absorbed it, as
in the last case, and the fact that any part had lost its vitality would then never
24 ON A NEW METHOD OF TREATING
have been known. That there is a reasonable ground for this belief will, I trust,
appear from the discussion in the succeeding section.
For a long time the progress of the patient continued satisfactory, the
process of union of the fragments advancing steadily, till in the early part of
February, the bone being firm, the splints were entirely discarded, and the case
was reduced from one of fracture to one of limited exfoliation. It was satis-
factory also to find that the knee-joint continued movable, so that I confidently
anticipated recovery, with a perfectly useful limb.
At this period, however, a new symptom presented itself—viz. haemorrhage
from the sinus. Mr. Hector Cameron, my present house surgeon, who saw the
first appearance of bleeding, supposed it to proceed from the surface of the
granulations ; for it was then small in amount, and ceased spontaneously.
Some days later, however—viz. on the 11th of February—a very profuse haemor-
rhage occurred, the blood soaking through the bed, and dropping upon the floor
beneath, before it was observed, and the gentleman who was summoned to see
the patient in Mr. Cameron’s absence, found him pulseless. He afterwards
rallied to some extent, but remained utterly prostrated, and unable to retain
the slightest nourishment. As the popliteal artery could be felt beating in the
lower part of the ham, I hoped that the source of the blood might be some
minor branch, which might possibly close. But it afterwards appeared that
a circular opening existed in the main vessel, occasioned no doubt by the pres-
sure of an irregular projection of the lower fragment. It would be irrelevant
to relate particularly the history of his yet further exhaustion by recurrent
haemorrhages after delusive temporary cessations, or of my attempts to restore
him by tying the popliteal artery, and making arrangements for transfusion, to
which he declined to submit. He died on the 25th of February.
The next four cases occurred in the practice of my colleagues in the infirmary,
who have kindly placed them at my disposal.
CASE 7.—Mary M——, aged sixty-two, was admitted under the care of
Dr. Morton on the 13th of August, 1866, at eleven p.m., when she stated that
about five o’clock in the afternoon of that day she missed her footing when going
downstairs, and fell with violence, and on getting up found that her right fore-
arm was broken and bleeding. A medical man was called in, who made various
applications in order to stop the haemorrhage, but failed to do so, and she
was advised to go to the infirmary. Mr. A. T. Thomson, the house surgeon (to
whom I am indebted for notes of the case), on removing the bandage, from
which blood was trickling, found both bones of the forearm broken a little
above the wrist, and a detached fragment of the radius projecting from a
COMPOUND FRACTURE, ABSCESS, ETC. 25
~
wound about as large as a fourpenny-piece, on the outer aspect of the limb.
Having extracted this fragment, he applied liquid carbolic acid thoroughly to
the interior of the wound. This rather increased the bleeding, which, however,
he arrested completely by plugging the orifice with a bit of lint dipped in the
acid. Over this he placed a mixture of blood and carbolic acid, covering it
with a piece of dry lint. He then put up the limb in two well-padded Gooch’s
splints, retained in position with a continuous bandage. The apparatus was
left undisturbed for five days, when, on removal of the splints, it was found
that the piece of dry lint over the wound, though it had been saturated with
blood, was quite dry, having become incorporated with the crust beneath.
It was not interfered with except that the surface was touched with carbolic
acid, and the splints were reapplied as before, the part being quite free from
uneasiness.
On the twelfth day the splints were again removed and the crust was
detached, when it was found that the piece of lint with which the wound had
been plugged had become partly pushed out of the orifice. The plug also was
now removed, when the surface beneath was observed to be granulating, but
entirely free from pus. The sore was dressed with one part of carbolic acid to
seven parts of olive oil applied on lint every second day, the use of the splints
being continued till the 8th of September, when she was discharged, with the
sore healed and both bones firmly united, two days less than four weeks after
the accident.
This case is valuable as an example of a mode in which troublesome bleeding
in compound fracture may sometimes be advantageously arrested. The entire
absence of pus about the plug on the twelfth day after its introduction con-
trasts strikingly with the suppuration invariably caused within four days by
a piece of lint inserted without carbolic acid into a wound.
CasE 8.—Samuel B——, aged thirteen, was admitted under Dr. Morton's
care,on the 30th of August,1866, with a compound fracture of the left femur, about
the junction of the upper and middle thirds of the shaft, and a simple fracture
of the right thigh in a similar situation. He stated that about four hours pre-
viously he was engaged in some work about a steam-engine, when he was struck
by one of the balls of the ‘ governor’, and hurled with great force against an
iron pillar. The men who brought him to the infirmary said that when he
was raised from the ground a piece of bone was seen to protrude from a wound
in the left thigh, but was restored to its natural position by a medical man
who was called in to see him, and who applied a long splint and bandage to each
limb. Mr. A. T. Thomsen, on examining the boy, found a lacerated wound
26 ON A NEW METHOD OF TREATING
about three inches long at the upper part of the left thigh, running transversely
from the middle of the inner side of the limb to its posterior aspect, and in this
wound the upper fragment of the femur was visible, somewhat displaced, but
not protruding. There was some bleeding, but not to any serious extent. He
sponged out the wound thoroughly with a solution of one part of carbolic acid
in three parts of olive oil, and then covered its lips with a mixture of blood
and the undiluted acid spread upon lint, and over this a piece of sheet-tin,
retained in position by means of a looped bandage. He next corrected the
faulty position of the fragments and applied lateral splints of Gooch’s material
to the thigh, maintaining gentle extension by means of plasters applied to the
integument of the leg after the American plan, and fixed to the foot of the bed,
a perineal band being attached to the bed-head. While the left limb was thus
kept readily accessible for changing the dressings, the long splint was employed
as usual for the simple fracture on the right side.
Next day the surface of the crust was touched with carbolic acid, and a hot
fomentation applied to the limb.
On the third day the crust was removed through a misunderstanding,
but it was resolved to follow out the treatment on the same principle, and with
this view the wound was dressed twice a day with lint dipped in the mixture
of carbolic acid and oil (one part to three), covered with the tin, as the crust
had been before, while the fomentations also were continued. Meanwhile the
limb remained free from pain, redness, or swelling, and there was a complete
absence of constitutional disturbance.
On the sixth day, however, he was a little feverish, and remained so, though
without any apparent local symptoms, till the twelfth day, when Mr. Thomson
noticed that the central part of the wound, which had become covered with
a whitish crust, was somewhat prominent, and, on careful examination, per-
ceived a distinct sense of fluctuation. He therefore removed the white layer
from that part, when eight ounces of perfectly odourless pus escaped. A probe
introduced failed to detect any bare bone. Mr. Thomson now sponged out
the cavity of the abscess with the mixture of carbolic acid and oil, and left in
it a strip of lint dipped in the same, continuing the other dressings as before.
The constitutional disturbance now at once subsided, and under the same dress-
ing the cavity of the abscess, quickly contracted, and in a little more than a fort-
night closed entirely. Six weeks after the accident the wound was completely
healed, and both the thigh-bones were firmly united, with the limbs of equal
length. In another week he was able to stand.
This case, which, I cannot avoid remarking, reflects great credit on the
house surgeon in charge, is interesting as another instance of the occurrence of
COMPOUND FRACTURE, ABSCESS, ETC. 27
abscess in compound fracture, independently of atmospheric influence. That
it was so in this instance is clearly shown by the entire absence of constitutional
symptoms for the first five days, the circumscribed character of the suppuration,
and the odourless nature of the pus. The injured part suppurated, probably
from the same cause as a severe bruise may without any breach of the integu-
ment. The satisfactory results obtained by treating the wound with carbolic
acid diluted with oil, instead of the undiluted acid, will naturally suggest the
inquiry whether this would not always be the better practice. And I may
mention that my former house surgeon, Dr. A. Cameron, met with similar
success in two cases in which he pursued the same treatment—one of them
a compound fracture of the ulna at the elbow, the other a severe contused wound
of the back of the hand communicating with a fractured metatarsal bone. But
considering how much is at stake, and that the patient’s life may depend upon
entire destruction of the septic germs that lie in the wound, I am inclined to
think it wiser to avail ourselves of the full energy of the pure acid, more especially
since we have had sufficient evidence that any caustic effects it may have are
not productive of serious consequences.
CAsE 9.—William C——, aged thirty-three, was admitted on the 29th of
September, 1866, under the care of Dr. Eben. Watson, with a compound
fracture of the left tibia, produced by an omnibus passing over the limb at
eight o’clock p.m. The broken part of the bone was exposed in a wound six
and a half inches in length, a little above the ankle. The skin in the vicinity
was detached from the subjacent tissues for about two inches, and there was
ecchymosis reaching some distance up the leg, with other evidence of severe
contusion.
An hour and a half after the accident Dr. A. Forsyth, the house surgeon,
from whose notes these particulars are obtained, sponged out the wound
thoroughly with undiluted carbolic acid, and placed over it layers of calico
soaked with the acid; and, in order to provide for a sufficiently substantial
crust, spread over the calico some paste composed of starch moistened with
carbolic acid, covering the whole with a piece of block-tin secured with a bandage,
the fracture being treated with a suitable apparatus. After the dressing, the
patient, though unable to express his feelings, being dumb, appeared entirely
free from uneasiness.
Next day the tin was carefully removed from the crust, the surface of which
was touched with carbolic acid, and, the tin having been readjusted, hot fomenta-
tions were applied to the leg and foot. The pulse was now 96, the tongue
clean, and appetite good. The same treatment was pursued till the thirteenth
28 ON A NEW METHOD OF TREATING
day, when the fomentations were discontinued, and. the edges of the crust
which were loose were clipped away, and lint moistened with water was applied
to the granulating surface thus exposed, the remainder of the crust being still
touched daily with carbolic acid. Meanwhile there had been no suppuration
beneath the crust, and the patient had remained free from constitutional
symptoms.
On the seventeenth day the crust, which had separated from the wound
at its lower third, was removed, disclosing a healthy granulating surface, the
bone being nowhere visible, while there was no appearance of pus, except a
trifling amount towards the lower part. The sore, which was entirely super-
ficial, was now treated like an ordinary ulcer, and healed quickly. The bone
also united as in a simple fracture, and he was discharged eight weeks after the
receipt of the injury, having been kept longer in the hospital than would other-
wise have been necessary, on account of a head affection to which he was subject.
The above case, besides being a good example of the effects of the treat-
ment of compound fracture with carbolic acid, affords an illustration of a practice
which I have on several occasions found useful when there has been but little
bleeding from the wound, a dough or paste composed of flour or starch, mois-
tened with the acid, being employed in lieu of the compound with blood to
render the crust sufficiently substantial.
CasE 10.—Thomas M‘B——, a labourer, who gave his age as fifty-two,
but had the appearance of a much older person, was admitted at noon on the
2nd of January, 1867, under the care of Dr. G. Buchanan, having been knocked
down an hour before by the shaft of a luggage wagon, the wheel of which passed
over his left leg, producing a compound fracture in the lower third of the limb.
Mr. James Robinson, the house surgeon, who has given me notes of the case,
found a wound from which blood was oozing, about an inch and a half in length,
exposing part of the tibia, and communicating with the seat of fracture. The
tissues were pretty severely contused. Undiluted carbolic acid was applied
freely to the interior of the wound by means of lint held in a pair of dressing-
forceps, and a crust was formed of blood mingled with the acid, covered with
lint, over which a cap of tin was placed, well bulged out to correspond to the
substantial crust, and large enough to overlap to a slight extent the sound skin
in the vicinity. The fragments having been brought into proper position, the
limb was put up with lateral wooden splints, with a hot fomentation. At the
conclusion of the dressing the patient expressed himself as greatly relieved.
The pulse was then 65.
Next day he was free from pain after a fair night’s rest. The pulse was 74,
COMPOUND FRACTURE, ABSCESS, ETC. 29
and the tongue clean and moist. The surface of the crust was touched with
carbolic acid, the limb being still fomented ; and the same treatment was con-
tinued daily for the following fortnight, during which the limb was entirely
free from pain, redness, or suppuration, while his constitution was quite un-
affected by the injury, the tongue remaining clean, and the pulse varying only
between 72 and 85.
I was present when the crust was removed, eighteen days after the accident.
Not a drop of pus existed beneath it. On the contrary, the superficial sloughs
of the cutis occasioned by the caustic action of the acid first applied remained
still undetached. The exposed surface was treated with water dressing, and
in two days presented the appearance of an ordinary granulating sore, which
healed without interruption. Six weeks and three days after the receipt of the
injury the splints were removed, the bones being satisfactorily united.
This is an excellent example of the effects of the carbolic-acid treatment
in a compound fracture of the leg of average severity. No simple fracture
could have caused less disturbance, either local or constitutional.
CasE 11.—The following case, though incomplete, is given on account of
the conclusive evidence it affords regarding a complication of compound fracture
of much interest both practically and theoretically—viz. emphysema of the
limb in consequence of air being introduced into the wound, and diffused among
the interstices of the tissues by a pumping action of the fragments of the broken
bone when freely moved through restlessness of the patient or carelessness of
his attendants before he comes under the surgeon’s care. Such a state of things
may seem at first sight to render it impossible to prevent decomposition of the
extravasated blood, since it would be out of the question to attempt to apply
carbolic acid to all the emphysematous tissues. But I have long indulged the
hope that, the air entering in small successive portions, its floating organisms
might be arrested by the first blood with which they came in contact, and
remain for some time confined to the vicinity of the external wound, in which
case, by squeezing out as much blood as possible from the orifice in the integu-
ment, and introducing carbolic acid freely, we might get rid of all causes of
decomposition in the limb, the mere atmospheric gases diffused more remotely,
however abundant, being entirely innocuous. This hope, it now appears, was
not ill-founded.
John D——, aged fifty-five, a calico-printer, of intemperate habits, was
admitted under my care in the Royal Infirmary at six p.m. on the 4th of April,
1867, having broken both bones of his right leg about an hour before by jumping
out of a window into the street, from a height of between fifteen and twenty
30 ON A NEW METHOD OF TREATING
feet, while in a state of intoxication. He was carried upstairs to his lodgings,
kicking about in his drunken frenzy. A cloth was then put round the leg,
but no efficient means were employed to steady it, and he was conveyed to
the hospital from a distant part of the city in a cab, moving the limb recklessly
during the whole journey. His friends stated that he had lost a great deal of
blood, and the cloth which was round the limb on his admission was saturated.
Mr. H. Cameron, the house surgeon, found a wound about half an inch in length,
situated over the spine of the tibia, at the junction of the middle and lower
thirds of the bone, the fracture being half an inch lower down, and obviously
communicating. The wound was bleeding very freely, and the leg was con-
siderably swollen through extravasation of blood into it. On manipulation,
Mr. Cameron found the tissues about the seat of fracture emphysematous, the
characteristic crackling sensation being experienced fully four inches above
the wound and two inches below it, and also on the opposite side of the limb,
over the fibula ; and as a result of the handling, a frothy mixture of blood and
air, in larger and smaller bubbles, escaped from the orifice. The fragments
were much displaced, the foot being greatly everted.
Mr. Cameron, having squeezed out as much blood as possible from the
wound, introduced melted crystallized carbolic acid in a piece of calico held
in dressing-forceps, which he passed in various directions for more than two
inches beneath the integument and about an inch and a half among the deeper
structures of the limb, using three different pieces of calico soaked with the
acid, and leaving the last in the wound as a plug to check the very free haemor-
rhage, which the treatment had considerably increased. He then applied several
layers of calico steeped in carbolic acid and smeared with blood, so as to make
a pretty thick crust overlapping the skin by about half an inch, and adapted
to the crust a cap of block-tin of slightly larger dimensions, pressing it down
upon the skin by means of a looped bandage encircling the leg. Having next
corrected the displacement of the fragments, he moulded a pasteboard splint
to the outer side of the leg and foot, strengthening it with a temporary Gooch’s
splint, and laid the limb on its outer side upon a pillow with the knee bent.
The patient now stated that the pain he had suffered was greatly relieved.
His pulse was 100. Two hours later, as a good deal of oozing of blood was
still going on, a folded cloth was placed upon the tin cap and pressed down upon
it with a bandage. The limb meanwhile was considerably more swollen, from
bleeding into its interior, kept up, no doubt, by the sudden jerking movements
which in his unreasoning condition he could not be prevented from making.
The pressure employed greatly diminished the external haemorrhage, but did
not entirely arrest it; and when two hours more had elapsed Mr. Cameron
COMPOUND FRACTURE, ABSCESS, ETC. 31
asked my advice. I recommended the use of a well-fitting internal splint, to
procure greater steadiness of the fragments, and so get rid of the irritation which
perpetuated the bleeding. Mr. Cameron, however, on removing the compress,
found that all tendency to oozing of blood had ceased. The patient was now
sober, but continued very restless. The internal splint was therefore applied,
and thirty drops of solution of muriate of morphia were administered.
During the night he suffered a good deal, and got no sleep at all. Next
morning, however, he complained rather of a general sense of weariness and
sickness, the consequences of his debauch, than of pain; the pulse had fallen
to 76; and he took his breakfast pretty well. The surface of the crust was
touched with carbolic acid, and this was repeated in the afternoon, when a hot
fomentation was applied to the inner side of the leg, and over this a sheet of
stout block-tin, to serve, as in some previous cases, the double purpose of ensur-
ing the efficiency of the fomentations, and acting as an internal splint. The
limb was now quite easy. At night the pulse was still 76. He had made a
pretty hearty supper, and felt only occasional twinges in the limb. The fomenta-
tion was changed, and the crust again touched with carbolic acid, and the opiate
repeated.
He passed the following night like the preceding, without getting any sleep
whatever ; and in the morning his pulse was go, although the limb was free
from pain or inflammatory blush, and he made a hearty breakfast. Fearing
the approach of traumatic delirium, I ordered a larger opiate to be given at
night. Fifty drops of the morphia solution were accordingly administered ;
and after this dose he slept for about five hours. Nevertheless, he grew more
restless, and was found in the morning with the leg fully extended and resting
on the calf instead of on its outer side. His pulse continued at go ; and although
the state of the limb and his appetite were all that could be wished, he exhibited
in the afternoon unmistakable signs of delirium tremens, jerking out his tongue
when asked to show it, twitching his hands in an excited manner, and declaring
that his bedclothes were creeping away from him, while the restless movements
of the limb were continued. I ordered a dose of castor oil, to be followed, as
soon as it should have operated, by a drachm of the solution of muniate of
morphia, to be repeated if necessary. He took the opiate about eight o'clock
p-m., and soon afterwards dozed a little; and at eleven his pulse had fallen
to 82. After this he fell into a sound sleep, from which he did not wake till
six a.m. ; and from this time forth he was perfectly tranquil and rational.
It is needless to enter into particulars regarding his subsequent progress
further than to say that it has been in all respects satisfactory ; and on the
tenth day after the accident, when I saw him last, his pulse was 76, his
32 ON A NEW METHOD OF TREATING
appetite excellent, and he had the appearance of a man in perfect health. The
limb was still free from pain, while the swelling due to extravasation of blood had
disappeared, and the skin was of natural aspect. After the second day from the
accident, there had not been even any discharge of serum from beneath the
crust, which had been daily touched with carbolic acid, the fomentations being
also continued, as he found them comfortable.
I need not hesitate to say that all danger in this case is over ; and that the
compound fracture is already converted into a simple one under circumstances
which, even for a simple fracture, would have been trying.
In revising the proof, after nine days more have elapsed, I may add that
all has continued to go on well.
PRELIMINARY NOTICE ON ABSCESS
I will now give a description of a new method of treating abscess, which
has afforded results so satisfactory that it does not seem right to withhold it
longer from the profession generally.
It is based, like the treatment of compound fracture, on the antiseptic
principle, and the material employed is essentially the same—namely, carbolic
acid, but differently applied in accordance with the difference of the circum-
stances. In compound fracture there is an irregular wound, which has prob-
ably been exposed to the air for hours before it is seen by the surgeon, and
may therefore contain in its interstices the atmospheric germs which are the
causes of decomposition, and these must be destroyed by the energetic applica-
tion of the antiseptic agent. In an unopened abscess, on the other hand, as
a general rule, no septic organisms are present, so that it is not necessary to
introduce the carbolic acid into the interior. Here the essential object is to
guard against the introduction of living particles from without, at the same
time that a free exit is afforded for the constant discharge of the contents. The
mode in which this is accomplished is as follows :—
A solution of one part of crystallized carbolic acid in four parts of boiled
linseed oil having been prepared, a piece of rag from four to six inches square
is dipped in the oily mixture, and laid upon the skin where the incision is to
be made. The lower edge of the rag being then raised, while the upper edge
is kept from slipping by an assistant, a common scalpel or bistoury dipped in
the oil is plunged into the cavity of the abscess, and an opening about three-
quarters of an inch in length is made, and the instant the knife is withdrawn
the rag is dropped upon the skin as an antiseptic curtain, beneath which the
COMPOUND FRACTURE, ABSCESS, ETC. 33
pus flows out into a vessel placed to receive it. The cavity of the abscess is
firmly pressed, so as to force out all existing pus as nearly as may be (the old
fear of doing mischief by rough treatment of the pyogenic membrane being
quite ill-founded) ; and if there be much oozing of blood, or if there be a con-
siderable thickness of parts between the abscess and the surface, a piece of lint
dipped in the antiseptic oil is introduced into the incision to check bleeding
and prevent primary adhesion, which is otherwise very apt to occur. The
introduction of the lint is effected as rapidly as may be, and under the pro-
tection of the antiseptic rag. Thus the evacuation of the original contents is
accomplished with perfect security against the introduction of living germs.
This, however, would be of no avail unless an antiseptic dressing could be
applied that would effectually prevent the decomposition of the stream of pus
constantly flowing out beneath it. After numerous disappointments, I have
succeeded with the following, which may be relied upon as absolutely trust-
worthy. About six teaspoonfuls of the above-mentioned solution of carbolic
acid in linseed oil are mixed up with common whitening (carbonate of lime) to
the consistence of a firm paste, which is in fact glazier’s putty with the addition
of a little carbolic acid. This is spread upon a piece of sheet block-tin about
six inches square; or common tinfoil will answer equally well if strengthened
with adhesive plaster to prevent it from tearing, and in some situations it is
preferable, from its adapting itself more readily to the shape of the part affected.
The putty forms a layer about a quarter of an inch thick ; it may be spread
with a table-knife, or pressed out with the hand, a towel being temporarily
interposed to prevent the putty from sticking to the hand or soiling the coat-
sleeve. The tin thus spread with putty is placed upon the skin so that the
middle of it corresponds to the position of the incision, the antiseptic rag used
in opening the abscess being removed the instant before. The tin is then fixed
securely by adhesive plaster, the lowest edge being left free for the escape of
the discharge into a folded towel placed over it and secured by a bandage. This
dressing has the following advantages: The tin prevents the evaporation of
the carbolic acid, which escapes readily through any organic tissue such as
oiled silk or gutta-percha. The putty contains the carbolic acid just sufficiently
diluted to prevent its excoriating the skin, while its substance serves as a
reservoir of the acid during the intervals between the dressings. Its oily nature
and tenacity prevent it from being washed away by the discharge, which all
oozes out beneath it as fast as it escapes from the incision; while the extent
of the surface of the putty renders it securely antiseptic. Lastly, the putty
is a cleanly application, and gives the surgeon very little trouble; a supply
being daily made by some convalescent in a hospital, or in private practice
LISTER II D
34 ON A NEW METHOD OF TREATING
by the nurse or a friend of the patient ; or a larger quantity may be made at
once, and kept in a tin canister. The dressing is changed, as a general rule,
once in twenty-four hours ; but if the abscess be a very large one, it is prudent
to see the patient twelve hours after it has been opened, when, if the towel
should be much stained with discharge, the dressing should be changed, to
avoid subjecting its antiseptic virtues to too severe a test. But after the first
twenty-four hours, a single daily dressing is sufficient. The changing of the
dressing must be methodically done, as follows: A second similar piece of tin
having been spread with the putty, a piece of rag is dipped in the oily solution,
and placed on the incision the moment the first tin is removed. This guards
against the possibility of mischief occurring during the cleansing of the skin
with a dry cloth and pressing out any discharge which may exist in the cavity.
If a plug of lint was introduced when the abscess was opened, it is removed
under cover of the antiseptic rag, which is taken off at the moment when the
new tin is to be applied. The same process is continued daily till the sinus
closes.
The results of this treatment are such as correct pathological knowledge
might have enabled us to predict. The pyogenic membrane has no innate
disposition to form pus, but does so only because it is subjected to some preter-
natural stimulus. In an ordinary abscess, whether acute or chronic, the original
cause that led to suppuration is no longer in operation, and the stimulus that
determines the continued pus-formation is derived from the presence of the pus
pent up in the interior. When an abscess is opened in the ordinary way this
cause of stimulation is removed, but in its place is substituted the potent stimulus
of decomposition. If, however, the abscess be opened antiseptically, the pyo-
genic membrane, freed from the operation of the previous stimulus without the
substitution of a new one, ought, according to theory, to cease to suppurate,
while the patient should be relieved from any local or general disturbance caused
by the abscess, without the risk of irritative fever or hectic.
Such, accordingly, is the fact. Abscesses of large size have, after the
original contents have been evacuated, furnished no further pus whatever, the
discharge being merely serum, which in a few days has amounted only to a few
drops in the twenty-four hours. Whether the opening be dependent or not
is a matter of perfect indifference, the small amount of unirritating fluid being
all evacuated spontaneously by the rapidly contracting pyogenic membrane.
At the same time, we reckon with perfect certainty on the absence of all
constitutional disturbance.
As an illustration, I may mention the last case which has come under my
care. It is that of a young woman, twenty-five years old, with psoas abscess,
eee
COMPOUND FRACTURE, ABSCESS, ETC. 35
which had of late been rapidly on the increase, and caused a large swelling below
Poupart’s ligament, communicating with a fluctuating mass, dull on percussion,
reaching to a considerable distance up the abdomen, the femoral vessels being
raised over the communication between them. Six days ago I opened, in the
manner above described, the swelling in the thigh at the anterior part of the
limb where it was nearest the surface, giving exit to twenty-seven ounces of
pus, thin, but containing numerous large curdy masses. I introduced a piece
of lint, dipped in the carbolic acid and oil, into the incision ; and this prevented
any discharge from escaping during the next twenty-four hours, when, on re-
moval of the plug of lint under an antiseptic rag, three ounces of turbid serum
escaped. For the next three days there was scarcely any discharge, the deeper
parts of the incision having cohered. On firm pressure, however, the product
of seventy-two hours escaped, and amounted to four drachms of serum. Mean-
while the girl’s general health, which had not been interfered with by the abscess,
continued perfectly good, neither pulse, tongue, appetite, nor sleep having been
disturbed.
In this case, though there is no deformity of the spine, there is great prob-
ability that caries of the vertebrae is present. But even though such be the
case, there is good reason to hope for a favourable issue. Regarding caries
as merely the suppurative stage of chronic inflammation in a weak form of
tissue, I have been not surprised, though greatly rejoiced, to find that it exhibits
the tendency of inflammatory affections generally—viz. a disposition to spon-
taneous cure on the withdrawal of irritation. Hitherto, in surgical practice,
caries has had to contend against the formidable irritation of decomposing
matter, which, under circumstances of weakness, is often sufficient to cause
ulceration, even in the soft parts; yet, in spite of this irritation, caries is often
recoverable in the child where the vital powers of all the tissues are stronger.
If, therefore, this serious complication can be avoided, there seems nothing in
theory against the probability that caries may prove curable in the adult. And
even should portions of necrosed bone be present, as is not infrequently the case,
our experience of the treatment of compound fracture with carbolic acid has
taught us that dead bone, if undecomposed, not only fails to induce suppuration
in its vicinity, but is liable to absorption by the granulations around It.’
Such were the hopes which I ventured to express several months ago to
my winter class. Since that time I have opened numerous abscesses connected
with caries of the vertebrae, the hip, knee, ankle, and elbow, and in all cases
I have found the discharge become in a few days trifling in amount, and in
many it has ceased to be puriform after the first twenty-four hours. Finally,
1 See p. 16 of this volume.
D2
36. A NEW METHOD OF TREATING COMPOUND FRACTURE, ETC:
three days ago—viz. on the 4th inst. (July 1867)—I had the inexpressible happi-
ness of finding the sinus soundly closed in a middle-aged man, in whom I opened
in February last a psoas abscess, proved to be connected with diseased bone
by the discharge, on one occasion, of an osseous spiculum. For months past
we had persevered with the antiseptic dressing, although the discharge did not
amount to more than a drop or two of serum in the twenty-four hours, well
knowing by bitter experience that so long as a sinus existed the occurrence
of decomposition might produce the most disastrous consequences; and at
length our patience has been crowned with success.
Hence I no longer feel any hesitation in recommending the early opening
of such abscesses, because, while they remain unopened, the disease of the bone
is necessarily progressive, whereas when opened antiseptically, there is good
ground to hope for their steady, though tedious, recovery.
The putty of the strength above recommended, though it generally fails to
excoriate the skin, sometimes produces this effect when long continued. In
such case it may be reduced in strength so that the oil contains only one part
to five or six without disadvantage when the discharge is very small in amount.
The application prevents the occurrence of cicatrization in the little sore
caused by the incision, and perpetuates a trifling discharge from it. Hence it is
impossible to judge whether or not the sinus has closed, except by examining
it from time to time with a probe, which should be dipped in the antiseptic oil,
and passed in between folds of the antiseptic rag. This may seem a refinement,
but if we could see with the naked eye a few only of the septic organisms that
people every cubic inch of the atmosphere of a hospital ward, we should rather
wonder that the antiseptic treatment is ever successful than omit any precau-
tions in conducting it.
The putty used in treating abscesses has proved very valuable in simplifying
the treatment of compound fracture, and enlarging the range of its applicability,
and also in dealing with incised wounds on the antiseptic principle. But I must
defer a notice of these matters to a future occasion.
ONY THE ANTISEPTIC .PRINCIPLE. INTHE
PRACTICE OF SURGERY
A paper read before the British Medical Association in Dublin on August 9, 1867.
[British Medical Journal, 1867, vol. ii, p. 246.]
In the course of an extended investigation into the nature of inflammation,
and the healthy and morbid conditions of the blood in relation to it, I arrived,
several years ago, at the conclusion that the essential cause of suppuration in
wounds is decomposition, brought about by the influence of the atmosphere
upon blood or serum retained within them, and, in the case of contused wounds,
upon portions of tissue destroyed by the violence of the injury.
To prevent the occurrence of suppuration, with all its attendant risks, was
an object manifestly desirable ; but till lately apparently unattainable, since
it seemed hopeless to attempt to exclude the oxygen, which was universally
regarded as the agent by which putrefaction was effected. But when it had
been shown by the researches of Pasteur that the septic property of the atmo-
sphere depended, not on the oxygen or any gaseous constituent, but on minute
organisms suspended in it, which owed their energy to their vitality, it occurred
to me that decomposition in the injured part might be avoided without excluding
the air, by applying as a dressing some material capable of destroying the life
of the floating particles.
Upon this principle I have based a practice of which I will now attempt to
give a short account.
The material which I have employed is carbolic or phenic acid, a volatile
organic compound which appears to exercise a peculiarly destructive influence
upon low forms of life, and hence is the most powerful antiseptic with which
we are at present acquainted.
The first class of cases to which I applied it was that of compound fractures,
in which the effects of decomposition in the injured part were especially striking
and pernicious. The results have been such as to establish conclusively the
great principle, that all the local inflammatory mischief and general febrile dis-
turbance which follow severe injuries are due to the trritating and poisoning influence
of decomposing blood or sloughs. For these evils are entirely avoided by the
antiseptic treatment, so that limbs which otherwise would be unhesitatingly
condemned to amputation may be retained with confidence of the best results.
38 ON THE ANTISEPTICYPRINCIPLE
In conducting the treatment, the first object must be the destruction of
any septic germs which may have been introduced into the wound, either at
the moment of the accident or during the time which has since elapsed. This
is done by introducing the acid of full strength into all accessible recesses of
the wound by means of a piece of rag held in dressing-forceps and dipped in
the liquid.1_ This I did not venture to do in the earlier cases ; but experience
has shown that the compound which carbolic acid forms with the blood, and
also any portions of tissue killed by its caustic action, including even parts
of the bone, are disposed of by absorption and organization, provided they are
afterwards kept from decomposing. We are thus enabled to employ the anti-
septic treatment efficiently at a period after the occurrence of the injury at
which it would otherwise probably fail. Thus I have now under my care in
the Glasgow Infirmary a boy who was admitted with compound fracture of the
leg as late as eight and a half hours after the accident, in whom nevertheless
all local and constitutional disturbance was avoided by means of carbolic acid,
and the bones were firmly united five weeks after his admission.
The next object to be kept in view is to guard effectually against the spread-
ing of decomposition into the wound along the stream of blood and serum which
oozes out during the first few days after the accident, when the acid originally
applied has been washed out, or dissipated by absorption and evaporation.
This part of the treatment has been greatly improved during the last few weeks.
The method which I have hitherto published? consisted in the application of
a piece of lint dipped in the acid, overlapping the sound skin to some extent,
and covered with a tin cap, which was daily raised in order to touch the surface
of the lint with the antiseptic. This method certainly succeeded well with
wounds of moderate size; and, indeed, I may say that in all the many cases
of this kind which have been so treated by myself or my house surgeons, not
a single failure has occurred. When, however, the wound is very large, the
flow of blood and serum is so profuse, especially during the first twenty-four
hours, that the antiseptic application cannot prevent the spread of decom-
position into the interior unless it overlaps the sound skin for a very considerable
distance, and this was inadmissible by the method described above, on account
of the extensive sloughing of the surface of the cutis which it would involve.
This difficulty has, however, been overcome by employing a paste composed
of common whitening (carbonate of lime) mixed with a solution of one part of
carbolic acid in four parts of boiled linseed oil, so as to form a firm putty. This
* The addition of a few drops of water to a considerable quantity of the crystallized acid induces
it to assume permanently the liquid form.
* See the preceding paper in this volume.
IN THE PRACTICE OF SURGERY 39
application contains the acid in too dilute a form to excoriate the skin, which it
may be made to cover to any extent that may be thought desirable, while its
substance serves as a reservoir of the antiseptic material. So long as any dis-
charge continues, the paste should be changed daily ; and, in order to prevent
the chance of mischief occurring during the process, a piece of rag dipped in
the solution of carbolic acid in oil is put on next the skin, and maintained there
permanently, care being taken to avoid raising it along with the putty. This
rag is always kept in an antiseptic condition from contact with the paste above
it, and destroys any germs that may fall upon it during the short time that
should alone be allowed to pass in the changing of the dressing. The putty
should be in a layer about a quarter of an inch thick, and may be advan-
tageously applied rolled out between two pieces of thin calico, which maintain
it in the form of a continuous sheet, that may be wrapped in a moment round
the whole circumference of a limb, if this be thought desirable, while the putty
is prevented by the calico from sticking to the rag which is next the skin.1 When
all discharge has ceased, the use of the paste is discontinued, but the original
rag is left adhering to the skin till healing by scabbing is supposed to be com-
plete. I have at present in the hospital a man with severe compound fracture
of both bones of the left leg, caused by direct violence, who, after the cessation
of the sanious discharge under the use of the paste, without a drop of pus appear-
ing, has been treated for the last two weeks exactly as if the fracture were a
simple one. During this time the rag, adhering by means of a crust of inspissated
blood collected beneath it, has continued perfectly dry, and it will be left un-
touched till the usual period for removing the splints in a simple fracture, when
we may fairly expect to find a sound cicatrix beneath it.
We cannot, however, always calculate on so perfect a result as this. More
or less pus may appear after the lapse of the first week; and the larger the
wound the more likely is this to happen. And here I would desire earnestly
to enforce the necessity of persevering with the antiseptic application, in spite
of the appearance of suppuration, so long as other symptoms are favourable.
The surgeon is extremely apt to suppose than any suppuration is an indication
that the antiseptic treatment has failed, and that poulticing or water dressing
should be resorted to. Butsuchacourse would in many cases sacrifice a limb or
a life. I cannot, however, expect my professional brethren to follow my advice
blindly in such a matter, and therefore I feel it necessary to place before them,
as shortly as I can, some pathological principles, intimately connected not
* In order to prevent evaporation of the acid, which passes readily through any organic tissue,
such as oiled silk or gutta percha, it is well to cover the paste with a sheet of block-tin, or tinfoil
strengthened with adhesive plaster. The thin sheet-lead for lining tea-chests will also answer the
purpose, and may be obtained from any wholesale grocer.
40 ON THE (ANTISEPTIC PRINCIPLE
only with the point we are immediately considering, but with the whole subject
of this paper.
If a perfectly healthy granulating sore be well washed and covered with
a plate of clean metal, such as block-tin, fitting its surface pretty accurately,
and overlapping the surrounding skin an inch or so in every direction, and
retained in position by adhesive plaster and a bandage, it will be found, on
removing it after twenty-four or forty-eight hours, that little or nothing that
can be called pus is present, merely a little transparent fluid, while at the same
time there is an entire absence of the unpleasant odour invariably perceived
when water dressing is changed. Here the clean metallic surface presenting
no recesses, like those of porous lint, for the septic germs to develop in, the
fluid exuding from the surface of the granulations has flowed away undecom-
posed, and the result is absence of suppuration. This simple experiment illus-
trates the important fact, that granulations have no inherent tendency to form
pus, but do so only when subjected to a preternatural stimulus. Further, it
shows that the mere contact of a foreign body does not of itself stimulate granu-
lations to suppurate; whereas the presence of decomposing organic matter
does. These truths are even more strikingly exemplified by the fact, which
I have elsewhere recorded,’ that a piece of dead bone, free from decomposition,
may not only fail to induce the granulations around it to suppurate, but may
actually be absorbed by them; whereas a bit of dead bone soaked with putrid
pus infallibly induces suppuration in its vicinity.
Another instructive experiment is to dress a granulating sore with some
of the putty above described, overlapping the sound skin extensively, when
we find in the course of twenty-four hours that pus has been produced by the
sore, although the application has been perfectly antiseptic ; and, indeed, the
larger the amount of carbolic acid in the paste the greater is the quantity of
pus formed, provided we avoid such a proportion as would act as a caustic.
The carbolic acid, though it prevents decomposition, induces suppuration—
obviously by acting as a chemical stimulus; and we may safely infer that
putrescent organic materials (which we know to be chemically acrid) operate in
the same way.
In so far, then, carbolic acid and decomposing substances are alike—namely,
that they induce suppuration by chemical stimulation, as distinguished from
what may be termed simple inflammatory suppuration, such as that in which
ordinary abscesses originate, where the pus appears to be formed in consequence
of an excited action of the nerves, independently of any other stimulus. There
is, however, this enormous difference between the effects of carbolic acid and
t See p. 16 of this volume.
IN THE’ PRACTICE OF SURGERY 4I
those of decomposition—viz. that carbolic acid stimulates only the surface to
which it is first applied, and every drop of discharge that forms weakens the
stimulant by diluting it. But decomposition is a self-propagating and self-
aggravating poison ; and if it occurs at the surface of a severely injured limb,
it will spread into all its recesses so far as any extravasated blood or shreds of
dead tissue may extend, and, lying in these recesses, it will become from hour
to hour more acrid till it acquires the energy of a caustic, sufficient to destroy
the vitality of any tissues naturally weak from inferior vascular supply, or
weakened by the injury they sustained in the accident.
Hence it is easy to understand how, when a wound is very large, the crust
beneath the rag may prove here and there insufficient to protect the raw surface
from the stimulating influence of the carbolic acid in the putty, and the result
will be, first, the conversion of the tissues so acted on into granulations, and
subsequently the formation of more or less pus. This, however, will be merely
superficial, and will not interfere with the absorption and organization of extra-
vasated blood or dead tissues in the interior; but, on the other hand, should
decomposition set in before the internal parts have become securely consolidated,
the most disastrous results may ensue.
I left behind me in Glasgow a boy, thirteen years of age, who between
three and four weeks previously met with a most severe injury to the left arm,
which he got entangled in a machine at a fair. There was a wound six inches
long and three inches broad, and the skin was very extensively undermined
beyond its limits, while the soft parts generally were so much lacerated that
a pair of dressing-forceps introduced at the wound, and pushed directly inwards,
appeared beneath the skin at the opposite aspect of the limb. From this wound
several tags of muscle were hanging, and among them there was one consisting
of about three inches of the triceps in almost its entire thickness ; while the
lower fragment of the bone, which was broken high up, was protruding four
and a half inches, stripped of muscle, the skin being tucked in underit. Without
the assistance of the antiseptic treatment, I should certainly have thought ot
nothing else but amputation at the shoulder-joint ; but as the radial pulse could
be felt, and the fingers had sensation, I did not hesitate to try to save the limb,
and adopted the plan of treatment above described, wrapping the arm from
the shoulder to below the elbow in the antiseptic application, the whole interior
of the wound, together with the protruding bone, having previously been freely
treated with strong carbolic acid. About the tenth day the discharge, which
up to that time had been only sanious and serous, showed a slight admixture
of slimy pus, and this increased till, a few days before I left, it amounted to
about three drachms in twenty-four hours. But the boy continued, as he had
42 ON THE ANTISE PTC PRINCIPLE
been after the second day, free from unfavourable symptoms, with pulse, tongue,
appetite, and sleep natural, and strength increasing, while the limb remained,
as it had been from the first, free from swelling, redness, or pain. I therefore
persevered with the antiseptic dressing, and before I left, the discharge was
already somewhat less, while the bone was becoming firm. I think it likely
that in that boy’s case I should have found merely a superficial sore had I taken
off all the dressings at the end of three weeks, though, considering the extent
of the injury, I thought it prudent to let the month expire before disturbing
the rag next the skin. But I feel sure that if I had resorted to ordinary dressing
when the pus first appeared, the progress of the case would have been exceed-
ingly different.
The next class of cases to which I have applied the antiseptic treatment
is that of abscesses. Here, also, the results have been extremely satisfactory,
and in beautiful harmony with the pathological principles indicated above.
The pyogenic membrane, like the granulations of a sore, which it resembles in
nature, forms pus, not from any inherent disposition to do so, but only because
it is subjected to some preternatural stimulation. In an ordinary abscess,
whether acute or chronic, before it is opened, the stimulus which maintains the
suppuration is derived from the presence of the pus pent up within the cavity.
When a free opening is made in the ordinary way, this stimulus is got rid of ;
but the atmosphere gaining access to the contents, the potent stimulus of de-
composition comes into operation, and pus is generated in greater abundance
than before. But when the evacuation is effected on the antiseptic principle,
the pyogenic membrane, freed from the influence of the former stimulus without
the substitution of a new one, ceases to suppurate (like the granulations of
a sore under metallic dressing), furnishing merely a trifling amount of clear
serum, and, whether the opening be dependent or not, rapidly contracts and
coalesces. At the same time any constitutional symptoms previously occasioned
by the accumulation of the matter are got rid of without the slightest risk of
the irritative fever or hectic hitherto so justly dreaded in dealing with large
abscesses.
In order that the treatment may be satisfactory, the abscess must be seen
before it has opened. Then, except in very rare and peculiar cases,’ there are
no septic organisms in the contents, so that it 1s needless to introduce carbolic
acid into the interior. Indeed, such a proceeding would be objectionable, as
it would stimulate the pyogenic membrane to unnecessary suppuration. All
‘ As an instance of one of these exceptional cases, I may mention that of an abscess in the vicinity
of the colon, and afterwards proved by post mortem examination to have once communicated with it.
Here the pus was extremely offensive when evacuated, and exhibited vibrios under the microscope.
IN THE PRACTICE OF SURGERY 43
that is necessary is to guard against the introduction of living atmospheric
germs from without, at the same time that free opportunity is afforded for the
escape of discharge from within.
I have so lately given elsewhere’? a detailed account of the method by
which this is effected, that it is needless for me to enter into it at present, further
than to say that the means employed are the same as those described above
for the superficial dressing of compound fractures—namely, a piece of rag dipped
in the solution of carbolic acid in oil, to serve as an antiseptic curtain, under
cover of which the abscess is evacuated by free incision; and the antiseptic
paste, to guard against decomposition occurring in the stream of pus that flows
out beneath it: the dressing being changed daily till the sinus has closed.
The most remarkable results of this practice in a pathological point of view
have been afforded by cases where the formation of pus depended upon disease
of bone. Here the abscesses, instead of forming exceptions to the general
class in the obstinacy of the suppuration, have resembled the rest in yielding
in a few days only a trifling discharge ; and frequently the production of pus
has ceased from the moment of the evacuation of the original contents. Hence
it appears that caries, when no longer labouring, as heretofore, under the irrita-
tion of decomposing matter, ceases to be an opprobrium of surgery, and recovers
like other inflammatory affections. In the publication before alluded to*
I have mentioned the case of a middle-aged man with psoas abscess depending
on diseased bone, in whom the sinus finally closed after months of patient per-
severance with the antiseptic treatment. Since that article was written I have
had another instance of success, equally gratifying, but differing in the circum-
stance that the disease and the recovery were both more rapid in their course.
The patient was a blacksmith who had suffered four and a half months before
I saw him from symptoms of ulceration of cartilage in the left elbow. These
had latterly increased in severity, so as to deprive him entirely of his night’s
rest and of appetite. I found the region of the elbow greatly swollen, and on
careful examination discovered a fluctuating point at the outer aspect of the
articulation. I opened it on the antiseptic principle, the incision evidently
penetrating to the joint, giving exit to a few drachms of pus. The medical
gentleman under whose care he was (Dr. Macgregor of Glasgow) supervised the
daily dressing with the carbolic-acid paste till the patient went to spend two
or three weeks at the coast, when his wife was entrusted with it. Just two
months after I opened the abscess he called to show me the limb, stating that
the discharge had for at least two weeks been as little as it then was—a trifling
moisture upon the paste, such as might be accounted for by the little sore caused
* See p. 32 of this volume, See p. 36 of this volume.
A4 ON THE ANTISEPTIC PRINCIPLE
by the incision. On applying a probe guarded with an antiseptic rag, I found
that the sinus was soundly closed, while the limb was free from swelling or
tenderness ; and, although he had not attempted to exercise it much, the joint
could already be moved through a considerable angle. Here the antiseptic
principle had effected the restoration of a joint which on any other known
system of treatment must have been excised.
Ordinary contused wounds are of course amenable to the same treatment
as compound fractures, which are a complicated variety of them. I will content
myself with mentioning a single instance of this class of cases. In April last
a volunteer was discharging a rifle, when it burst, and blew back the thumb
with its metacarpal bone, so that it could be bent back as on a hinge at the
trapezial joint, which had evidently been opened, while all the soft parts between
the metacarpal bones of the thumb and fore-finger were torn through. I need
not insist before my present audience on the ugly character of such an injury.
My house surgeon, Mr. Hector Cameron, applied carbolic acid to the whole raw
surface, and completed the dressing as if for compound fracture. The hand
remained free from pain, redness, or swelling, and, with the exception of a shallow
groove, all the wound consolidated without a drop of matter, so that if it had
been a clean cut, it would have been regarded as a good example of primary
union. The small granulating surface soon healed, and at present a linear
cicatrix alone tells of the injury he had sustained, while his thumb has all its
movements and his hand a firm grasp.
If the severest forms of contused and lacerated wounds heal thus kindly
under the antiseptic treatment, it is obvious that its application to simple incised
wounds must be merely a matter of detail. I have devoted a good deal of
attention to this class, but I have not as yet pleased myself altogether with
any of the methods I have employed. I am, however, prepared to go so far
as to say that a solution of carbolic acid in twenty parts of water, while a mild
and cleanly application, may be relied on for destroying any septic germs that
may fall upon the wound during the performance of an operation; and also
that for preventing the subsequent introduction of others, the paste above
described, applied as for compound fractures, gives excellent results. Thus
I have had a case of strangulated inguinal hernia, in which it was necessary to
take away half a pound of thickened omentum, heal without any deep-seated
suppuration or any tenderness of the sac or any fever; and amputations, in-
cluding one immediately below the knee, have remained absolutely free from
constitutional symptoms.
Further, I have found that when the antiseptic treatment is efficiently
conducted, ligatures may be safely cut short and left to be disposed of by
IN THE PRACTICE OF SURGERY 45
absorption or otherwise. Should this particular branch of the subject yield
all that it promises, should it turn out on further trial that when the knot is
applied on the antiseptic principle, we may calculate as securely as if it were
absent on the occurrence of healing without any deep-seated suppuration ;
the deligation of main arteries in their continuity will be deprived of the two
dangers that now attend it—namely, those of secondary haemorrhage and an
unhealthy state of the wound. Further, it seems not unlikely that the present
objection to tying an artery in the immediate vicinity of a large branch may
be done away with; and that even the innominate, which has lately been the
subject of an ingenious experiment by one of the Dublin surgeons on account
of its well-known fatality under the ligature from secondary haemorrhage,
may cease to have this unhappy character, when the tissues in the vicinity of
the thread, instead of becoming softened through the influence of an irritating
decomposing substance, are left at liberty to consolidate firmly near an un-
offending though foreign body.
It would carry me far beyond the limited time which, by the rules of the
Association, is alone at my disposal, were I to enter into the various applications
of the antiseptic principle in the several special departments of surgery.
There is, however, one point more that I cannot but advert to—namely, the
influence of this mode of treatment upon the general healthiness of a hospital.
Previously to its introduction, the two large wards in which most of my
cases of accident and of operation are treated were amongst the unhealthiest
in the whole surgical division of the Glasgow Royal Infirmary, in consequence,
apparently, of those wards being unfevourably placed with reference to the
supply of fresh air ; and I have felt ashamed, when recording the results of my
practice, to have so often to allude to hospital gangrene or pyaemia. It was
interesting, though melancholy, to observe that, whenever all, or nearly all,
the beds contained cases with open sores, these grievous complications were
pretty sure to show themselves ; so that I came to welcome simple fractures,
though in themselves of little interest either for myself or the students, because
their presence diminished the proportion of open sores among the patients.
But since the antiseptic treatment has been brought into full operation, and
wounds and abscesses no longer poison the atmosphere with putrid exhalations,
my wards, though in other respects under precisely the same circumstances as
before, have completely changed their character ; so that during the last nine
months not a single instance of pyaemia, hospital gangrene, or erysipelas has
occurred in them.
As there appears to be no doubt regarding the cause of this change, the
importance of the fact can hardly be exaggerated.
ILLUSTRATIONS OF THE ANTISEPTIC SYSTEM OF
TREATMENT IN SURGERY
[Lancet, 1867, vol. i, p. 668.]
it
DECOMPOSITION or putrefaction has long been known to be a source of
great mischief in surgery, and antiseptic applications have for several years
been employed by many surgeons. But the full extent of the evil, and the
paramount importance of adopting effectual measures against it, are far from
being generally recognized.
It is now six years since I first publicly taught in the University of Glasgow
that the occurrence of suppuration in a wound under ordinary circumstances,
and its continuance on a healthy granulating sore treated with water dressing,
are determined simply by the influence of decomposing organic matter. The
subject has since received a large share of my attention, resulting in the system
of treatment which I have been engaged for the last three years in elaborating.
The benefits which attend this practice are so remarkable that I feel it incumbent
upon me to do what I can to diffuse them ; and with this view I propose to
present to the readers of the Lancet a series of illustrative cases, prefacing them
with a short notice of the principles which it is-essential to bear in mind in order
to attain success."
The cases in which this treatment is most signally beneficial are divisible
into three great classes—incised wounds, of whatever form ; contused or lacerated
wounds, including compound fractures; and abscesses, acute or chronic—
a list, indeed, which comprises the greater part of surgery. In each of these
groups our aim is simply to prevent the occurrence of decomposition in the
part, in order that its reparatory powers may be left undisturbed by the irritat-
ing and poisoning influence of putrid materials. In pursuing this object we
are guided by the ‘germ theory’, which supplies us with a knowledge of the
nature and habits of the subtle foe we have to contend with; and without
a firm belief in the truth of that theory, perplexity and blunders must be of
frequent occurrence. The facts upon which it is based appear sufficiently
* This plan seems preferable to continuing the formal communication, of which Part I has appeared
in preceding pages of this journal (pp, 1-36 of this volume) since I shall thus be left untrammelled as to
the order in which the subjects are introduced, and shall be at liberty to notice from time to time any im-
provements that may suggest themselves in the methods of dealing with the various classes of cases.— J. L.
THE ANTISEPTIC SYSTEM IN SURGERY 47
convincing. We know from the researches of Pasteur that the atmosphere
does contain among its floating particles the spores of minute vegetations and
infusoria, and in greater numbers where animal and vegetable life abound, as
in crowded cities or under the shade of trees, than where the opposite conditions
prevail, as in unfrequented caves or on Alpine glaciers. Also, it appears that
the septic energy of the air is directly proportioned to the abundance of the
minute organisms in it, and is destroyed entirely by means calculated to kill
its living germs—as, for example, by exposure for a while to a temperature of
212° Fahr., or a little higher, after which it may be kept for an indefinite time
in contact with putrescible substances, such as urine, milk, or blood, without
producing any effect upon them. It has further been shown, and this is particu-
larly striking, that the atmosphere is deprived of its power of producing decom-
position as well as organic growth by merely passing in a very gentle stream
through a narrow and tortuous tube of glass, which, while it arrests all its solid
particles, cannot possibly have any effect upon its gases; while conversely,
‘ air-dust ’ collected by filtration rapidly gives rise simultaneously to the develop-
ment of organisms and the putrefactive changes. Lastly, it seems to have
been established that the character of the decomposition which occurs in a
given fermentable substance is determined by the nature of the organism that
develops in it. Thus the same saccharine solution may be made to undergo
either the vinous or the butyric fermentation, according as the yeast plant or
another organism, described by Pasteur, is introduced into it.' Hence we
cannot, I think, refuse to believe that the living beings invariably associated
with the various fermentative and putrefactive changes are indeed their causes.
And it is peculiarly in harmony with the extraordinary powers of self-diffusion
and penetration exhibited by putrefaction that the chief agents in this process
appear to be ‘ vibrios’ endowed with the faculty of locomotion, so that they
are able to make their way speedily along a layer of fluid such as serum
or, pus.”
Admitting, then, the truth of the germ theory, and proceeding in accor-
dance with it, we must, when dealing with any case, destroy in the first instance
once for all any septic organisms which may exist within the part concerned ;
and after this has been done, our efforts must be directed to the prevention
of the entrance of others into it. And provided that these indications are
really fulfilled, the less the antiseptic agent comes in contact with the living
+ See Pasteur’s papers in the Comptes Rendus, vols. 1, li, lii, lvi, also a report by Milne Edwards
on experiments performed by Pasteur before a committee of the French Academy ; Annales des Sciences
Naturelles, March and April 186s.
* I have seen vibrios, so minute as to be only just discernible with the highest power of an excellent
microscope, shoot across the field of view with a velocity that astonished me.
48 ILLUSTRATIONS OF THE ANTISEPTIG SYSTEM
tissues the better, so that unnecessary disturbance from its irritating properties
may be avoided.
The simplest conditions are presented by an unopened abscess. Here,
as no septic particles are present in the contents, it is needless to apply the
antiseptic directly to the part affected. All that is requisite is to guard securely
against the possibility of the penetration of living germs from without, at the
same time that free escape is afforded for the discharge from within. When
this is done we witness an example of the unaided curative powers of Nature
as beautiful as it is, I believe, entirely new. The pyogenic membrane, freed
from the operation of the stimulus derived from the presence of the pus pent up
within it, without the substitution of the powerful stimulus of decomposition
as has heretofore been the case after the opening of abscesses, ceases at once
to develop pus-corpuscles, and, exuding merely a little clear serum, rapidly
contracts and coalesces, discharging meanwhile its unirritating contents com-
pletely, whether the outlet be dependent in position or otherwise. At the same
time the irritative fever and hectic hitherto so much dreaded in large abscesses
are, with perfect security, entirely avoided.
In suppurations of the vertebrae or of the joints the results of this system
are such as I ventured with trembling hope to anticipate ; patient perseverance
being rewarded by a spontaneous cure in cases where excision, amputation, or
death must have resulted from any other known system of treatment. In short,
the element of incurability has been eliminated from caries.
In compound fractures and other severe contused wounds the antiseptic
agent must in the first instance be applied freely and energetically to the injured
parts themselves, the conditions being the opposite of those in unopened
abscesses. The wound being of complicated form, with its interstices loaded
with extravasated blood, into which septic organisms may have already in-
sinuated themselves during the time that has elapsed before the patient is seen
by the surgeon, mere guarding of the external orifice, however effectually, is
not sufficient. After squeezing out as much as possible of the effused blood,
a material calculated to kill the septic particles must be introduced into the
recesses of the wound; and if the substance employed is of sufficient strength
to operate to a certain extent as a caustic, this is regarded as a matter of little
moment in comparison with the terrible evil of inefficiency in its antiseptic
action. For experience has abundantly shown that parts killed in this way,
including even portions of bone, become disposed of by absorption and
organization, provided that the subsequent part of the treatment is properly
managed.
Sloughs, as ordinarily observed, are soaked with the acrid products of
OF TREATMENT IN SURGERY 49
decomposition, and therefore produce disturbance upon the.tissues around them,
leading first to their gradual transformation into the rudimentary structure
which, when met with at the surface of a sore, is termed ‘ granulations’, and
afterwards to the formation of pus by the granulations. But a dead portion of
tissue, if not altered by adventitious circumstances, is in its proper substance
perfectly bland and unirritating, and causes no more disorder in its neighbourhood
than a bullet or a piece of glass, which may remain imbedded in the living body
for an indefinite period without inducing the formation of pus ; while the dead
tissue differs from the foreign bodies alluded to in the circumstance that the
materials of which it is composed are susceptible of absorption.
Antiseptic substances, being, like the products of decomposition, chemically
stimulating, will, ike them, induce granulation and suppuration in tissues
exposed for a sufficient length of time to their influence ; but there is this all-
important difference, that an antiseptic merely stimulates the surface to which
it is applied, becoming diluted and weakened by the discharge which it excites ;
but the acrid salts which result from putrefaction are perpetually multiplied
and intensified by self-propagating ferments, so that every drop of serum or
pus effused through their agency becomes a drop of poison, extending its baleful
influence both in the injured part and in the system generally.
These pathological considerations indicate the after-treatment in com-
pound fracture, and explain the progress of the case. The antiseptic intro-
duced into the wound is soon washed out by the discharge or carried away by
the circulation, so that the blood and sloughs at first imbued with it become
unstimulating and amenable to absorption, while at the same time they are
prone to decomposition should any living atmospheric germs gain access to
them. The further treatment, therefore, must consist in maintaining an efficient
antiseptic guard over the orifice of the wound until sufficient time has elapsed
to ensure complete consolidation of the injured parts.
The sanious and serous discharge which occurs at the outset will give place
in a few days to asmall amount of pus, if the wound is dressed in such a way
that the antiseptic continues to act upon the raw surface. This discharge,
due to the stimulating nature of the application, being merely superficial, and
involving no inflammatory or febrile disturbance, will occasion no anxiety to
one who understands its cause; and I venture to repeat the caution given in
a previous communication,’ that the surgeon must on no account be induced
to explore the wound and pry into the source of the suppuration, so long as all is
going on well otherwise ; for such a course, by admitting germs into the interior,
may produce the most disastrous consequences in an otherwise promising case.
' See p. 39 of this volume.
LISTER II E
50 THE ANTISEPTIC SYSTEM OF TREATMENT IN SURGERY
But although suppuration resulting from the stimulating influence of the
antiseptic is no cause for anxiety, it is more convenient that it should be avoided;
and this may often be done entirely by leaving the lower layers of the dressing
permanently on the limb and changing only its superficial parts—a plan which,
while it protects the wound against the introduction of mischievous particles,
permits the foreign body in contact with the tissues to part with its antiseptic
material and become an unstimulating crust, under which complete healing by
scabbing may occur in wounds of a size hitherto regarded as inconsistent with
this process in the human subject.
Upon these principles a really trustworthy treatment for compound frac-
tures and other severe contused wounds has been established for the first time,
so far as I am aware, in the history of surgery. In a hospital which receives
an unusually large number of patients suffering from machinery accidents,
and in wards which, from circumstances to which I need not here allude, were
peculiarly unhealthy, my experience of compound fracture in the lower limb
was formerly far indeed from satisfactory, even in the selected cases in which
alone I attempted to save the limb. But since the antiseptic principle has
guided us, not only have ordinary cases of this formidable injury been treated
by my successive house surgeons with unvarying success, but limbs such as
I should once have condemned without hesitation have gone on to complete
recovery without either local or constitutional disturbance : a statement which
might be suspected of exaggeration were it not that it refers to proceedings
in a public hospital, witnessed not only by students, but by gentlemen once
my pupils, and now practitioners in Glasgow.
In the next article I propose, after a few words regarding the principles
applicable to simple incised wounds, to describe in detail the methods of pro-
cedure, illustrated by cases.
AN ADDRESS ON THE ANTISEPTIC SYSTEM
OF TREATMENT IN SURGERY '
Delivered before the Medico-Chirurgical Society of Glasgow.
[British Medical Journal, 1868, vol. ii, pp. 53, 101, 461, 515; 1869, vol. i, p. 301.]}
Mr. PRESIDENT AND GENTLEMEN.—In order that the antiseptic system of
treatment may confer upon mankind all the benefits of which it is capable,
three things appear to be indispensably requisite. First, that every surgeon
should be convinced of the reality and greatness of those benefits, so that he
may be induced to devote to the antiseptic dressing of a case the same kind
of thought and pains as he now, if at all worthy of the name of surgeon, bestows
upon the planning and execution of an operation ; secondly, that these efforts
on his part should be directed on sound principles ; and thirdly, that, for carry-
ing out these principles, he should have thoroughly trustworthy practical means
at his disposal. I venture to hope that the illustrations which I propose to bring
before you this evening may promote in some degree each of these essentials.
In speaking of the antiseptic system of treatment, I refer to the systematic
employment of some antiseptic substance, so as entirely to prevent the occur-
rence of putrefaction in the part concerned, as distinguished from the mere
use of such an agent as a dressing. The latter has long been practised in many
parts of the world. The former originated rather more than three years ago
in this city (Glasgow). The material which I have generally used for the
purpose is carbolic (or phenic) acid, which, when I first published on the subject,
was new to most British surgeons as an external therapeutic agent. This
circumstance, while it had the effect of attracting greater notice to the matter
than might otherwise have been the case, was perhaps on the whole a misfortune,
since it tended to distract attention from the essential principles of the treat-
ment which I advocated, and to lead many in this country to look upon carbolic
acid in the light of a specific. On the other hand, continental surgeons visiting
our infirmary, familiar with the use of carbolic acid as an ordinary antiseptic
dressing, have invariably formed a just estimate of the advantages derived
from its employment upon the system to which I have alluded.
* This address does not profess to give a complete account of the antiseptic system, but was based
upon some illustrations which happened to be at my disposal. One of these, an experiment in support
of the germ theory of putrefaction, was dwelt upon at considerable length, in accordance with what
I believe to be the great practical importance of the subject to which it refers.
EZ
52 ON THE ANTISEPTIC SYSTEM
So far from carbolic acid being a specific, it owes its virtues to properties
which it possesses in common with various other substances ; and results similar
in kind to those obtained by its means might be got by disinfectants long
familiar to British surgery, provided always that the same principles guided their
employment. This statement is not made on theoretical grounds alone. About
nine months after I had first treated compound fracture with carbolic acid,
Mr. Campbell De Morgan published a paper ‘ On the Use of Chloride of Zinc in
Surgical Operations and Injuries’, and was kind enough to send me a copy of
it. By means of this salt he had obtained highly satisfactory results, though
led to employ it with a very different object in view. Mr. De Morgan used
chloride of zinc in the first instance in cases of cancer, upon the idea that the
frequency of return of the disease after operation might depend on the dis-
semination of its germs on the cut surface, and he hoped that, by applying
a strong solution of the chloride to the wound so as to destroy any cancer-germs
that might be scattered over it, he might diminish the chance of recurrence.
Having treated cases of cancer in this way, he found that the wounds healed
unusually kindly, while there was, at the same time, an absence of ‘ animal
odour’, and he expressed his surprise at the small amount of ‘action’ in the
part. To myself it appeared perfectly natural that, if chloride of zinc prevented
animal odour, implying that putrefaction was avoided, the wound, protected
from the irritating influence of the products of decomposition, should exhibit
little inflammatory disturbance. But it struck me as very remarkable that
a single application of chloride of zinc to the raw surface should have the effect
of preventing all odour of putrefaction for days afterwards ; for I knew that
in the case of carbolic acid a renewal of the antiseptic to the exterior was essential
in order to prevent decomposition. Hence it appeared likely that chloride
of zinc would answer better for my purpose than carbolic acid, and I deter-
mined, on the first suitable occasion, to give it a trial. It was not long before
an opportunity presented itself.
Case of Compound Fracture Treated with Chloride of Zinc.—A labourer was
admitted into the infirmary with compound depressed fracture of the os frontts,
caused by violent impact of the handle of a winch. I applied chloride-of-zinc
solution thoroughly to the interior of the wound, and, with the view of prevent-
ing the spreading of decomposition inwards, adapted to the forehead a plate
of clean block-tin overlapping the sound skin for a considerable distance, a means
which, as I had before ascertained, prevents the occurrence of putrefaction
in the discharge from a healthy granulating sore. The tin plate was kept in
position by a piece of strapping, and over all was laid a damp folded rag to
absorb discharge, with directions that it should be frequently changed. The
OF TREATMENT IN SURGERY 53
tin was not disturbed till about a week had expired, the patient meanwhile
remaining free from any unfavourable symptoms, and not a drop of pus appear-
ing. On removing the plate of metal, I found that the wound, instead of being
hollow as when I had last seen it, was on a level with the surface of the forehead,
being occupied by a chocolate-coloured mass which I supposed to be a clot,
altered by the action of chloride of zinc. But when I scraped the surface of
this material it bled, showing that it was in reality alive and vascular. This
exactly corresponded to the most striking and peculiar of the results I had seen
to follow the use of carbolic acid in compound fracture, and the most likely to
be mistaken for the effect of a specific action of that substance, viz. that the
blood acted on by the antiseptic, though greatly altered by that action,
remained susceptible of organization. Or, speaking more strictly, the product
of the action of chloride of zinc upon the blood, like that of the operation of
carbolic acid upon it, so soon as the irritating antiseptic material with which it
was at first imbued had been withdrawn from it by diffusion into the surrounding
circulation, proved a suitable pabulum for the growing elements of living tissue
in the vicinity, which accordingly absorbed and appropriated it.
In the case just related, nothing could be more satisfactory than the effects
of chloride of zinc. Subsequent trials, however, proved it to be very inferior
to carbolic acid except in one class of cases, those, viz., in which, from the cir-
cumstances of the part concerned, it is impossible to maintain an efficient external
antiseptic dressing, so that the application must be made once for all at the
time of the operation. Here the permanence of the effects of chloride of zinc
renders it highly valuable, as, for example, after the removal of portions of the
maxillary bones. Every surgeon is familiar with the highly offensive character
of the discharge for the first few days after such operations ; and there can be
no doubt that the fetid state of the wound, besides being a great inconvenience
to the patient and his attendants, involves a certain amount of danger. By
means of chloride of zinc this complication is nearly, if not entirely avoided.
In the first case of this kind in which I used it, I had to remove a considerable
portion of both superior maxillary bones, on account of epithelial cancer which
had spread to them from the face. I applied the chloride-of-zinc solution
freely to the raw surfaces at the time of the operation, and afterwards examined
the breath daily, when the only smell perceptible from first to last was an occa-
sional odour of tobacco. [Since this address was delivered, I have used chloride
of zinc with great advantage after the removal of the tongue by Mr. Syme’s
method, in a case of epithelial cancer. |
But in ordinary cases carbolic acid is very superior to chloride of zinc,
" See p. 8 of this volume.
54 ON THE ANTISEPTIC SYSTEM
and, so far as I am able to judge, to any other antiseptic agent with which we
are at present acquainted. It presents, indeed, a remarkable combination of
advantages. In the first place, it possesses the essential requisite of being
a most potent poison for the low forms of life which determine putrefaction,
and it retains this power even though diluted to such a degree as to be almost
entirely unirritating to the tissues of the human body. In the second place,
it is volatile, and its vapour is quite efficacious as an antiseptic. This gives
it a great advantage over chloride of zinc or any other non-volatile substance,
enabling the dressings impregnated with the acid to exert their influence not
only upon objects in actual contact with them, but also upon the air in their
vicinity. Again, carbolic acid is a local anaesthetic, and exercises a most sooth-
ing influence upon a painful wound. Lastly, carbolic acid is soluble in a variety
of liquids of very different properties, so different, for example, as water and the
fixed oils ; and each of these solutions has its own special value in practice, a point
to which I shall have occasion to allude further on in this communication.
And now, before speaking of some cases treated with carbolic acid on the
antiseptic system, I wish to direct your attention to an experiment illustrating
the germ theory of putrefaction. It is on this theory that the antiseptic system
of treatment is based; and I venture to say that, without a belief in the truth
of that theory, no man can be thoroughly successful in the treatment. If any
one believe that putrefaction, through atmospheric influence, is due to the
operation of the atmospheric gases alone upon the putrescible materials, he
will be perpetually meeting with the most perplexing anomalies, and will be
liable to commit the most serious practical blunders; the truth being that,
on the one hand, the complete exclusion of the gases of the air affords no security
against the occurrence of putrefaction, and that, on the other hand, the freest
admixture of air with the putrescible contents of a wound or abscess will fail
to induce putrefactive changes, if the germs of that air have been removed by
filtration or deprived of vitality by a germ-poison. Of this I might, if time
permitted, give several very striking illustrations from practical surgery.
The experiment which I wish to bring under your notice is a modification
of one described by Pasteur,’ not, indeed, as originated by himself, but by
M. Chevreul. It is so simple, and, at the same time so conclusive, that it should,
I think, if believed, carry conviction to the minds of all. To myself the state-
ment of Pasteur, confirmed as it is by the report of the Commission of the
French Academy, before whom this, as well as various others of his experiments
was performed, was perfectly satisfactory. But there was one reason that
made me anxious to repeat the experiment as bearing upon the antiseptic
* Comptes Rendus, vol. 1, p. 306.
OF TREATMENT IN SURGERY 55
system of treatment ; and this was that, so far as I read Pasteur’s papers, he
had performed it only with reference to the fermentation of a saccharine solution,
and I wished to make sure that it applied equally to putrefaction. The experi-
ment was performed in the following manner.
Experiment in support of the Germ Theory of Putrefaction.
On the 26th of October, just half a year ago, I introduced portions of the same
specimen of fresh urine into four flasks, of which these are two. |The flasks, which
were capable of containing about six fluid ounces each, were about one-third filled. |
After washing the urine from their necks, which were then wide and straight,
I drew out the necks by means of a spirit-lamp into tubes about a line in
diameter, and in three of the flasks bent these elongated and attenuated necks
at various acute angles, as you will see in one of the two before you. In the
remaining flask, the neck was cut short and left vertical in position as you see
it here, but its orifice was reduced to even smaller calibre than in the others.
Fach flask was then boiled over the lamp, and the fluid maintained in a state
of ebullition for five minutes, the steam issuing freely from the orifice. The
lamp was then withdrawn, and atmospheric air was permitted to rush into the
flask to supply the place of the condensed steam. The flasks were then left
undisturbed in the same room, the ends of their necks being still open so as to
permit free exit and entrance of air as a consequence of the diurnal changes of
temperature which, of course, involved alternate expansions and condensations
of the contained gases. Sometimes on a cold night I have raised the tem-
perature of the apartment considerably, and then putting the fire out, have
thrown open the windows so as to occasion a depression of temperature of
twenty degrees, involving the entrance of about a cubic inch of fresh air into
the body of each flask. But, independently of any such exceptional treatment,
a perpetual daily interchange took place between the air inside the flasks and
that of the room in which they stood. And what has been the result of the
action of the air upon the urine? In the flask with straight and short, though
narrow neck, I observed after ten days a minute filamentous object at the
bottom of the glass. It grew larger from day to day, and was evidently a kind
of minute vegetation ; and on applying a pocket magnifier, it was seen to con-
sist of delicate branching threads. Four days after this growth first appeared,
I observed an object floating on the surface of the liquid, evidently also a minute
fungus ; but this in the course of a few days clearly showed itself to be of
a different kind, consisting of straight radiating filaments much more closely
packed, while to the naked eye its appearance was much denser than the other,
which was beautifully feathery and delicate, and its colour bluish-grey instead
56 ON THE ANTISEPTIC SYSTEM
of perfectly colourless like the first. The two differed also remarkably in their
rate of growth, that at the bottom of the vessel springing up with rapidity,
so that a month after the commencement of the experiment it occupied about
half the mass of the fluid, while the floating kind, though it had been steadily
enlarging, had attained only about the size of a pea. Meanwhile the urine
had been undergoing a change in chemical constitution, as was indicated by
an alteration of its colour from a pale straw to a deep amber tint. But in the
meantime, what was the condition of the urine in the three other flasks, with
bent necks, of which this is a sample? You observe it is perfectly clear and
bright, free from cloud, scum, or sediment, and it retains its original straw
colour, contrasting strikingly with the amber tint of the other. In short, it
has precisely the same appearance as it had at the outset. I may add that,
on the day after these flasks were prepared, having another similar one at my
disposal, I introduced into it some fresh urine from the same source, drew out
the neck and bent it into angular form, and treated it like the others, so that
I have thus four flasks of boiled urine communicating with the air through bent
tubes ; and in all of these the urine has remained with unchanged colour and
undiminished transparency. It can hardly be doubted that this completely
unaltered appearance of the fluid is associated with absence of putrefaction.
I shall take an early opportunity of ascertaining whether such is the fact or
not ; but in the meantime, suppose we assume that it is so. [Since the delivery
of this address, namely on the 2nd inst. (May 1868), I poured out about half an
ounce of urine from one of the flasks with bent neck into a wine-glass, and
examined it. Its odour was perfectly sweet, and its reaction faintly acid to
litmus paper, while under the microscope it showed not the slightest appearance
of anything possessing vitality. I then covered the wine-glass with a piece
of sheet gutta-percha to prevent evaporation, and left it at a temperature of
about seventy degrees. Three days later it had already lost its brilliant trans-
parency, and a distinct change had occurred in its odour, which had assumed
something of the smell that urine has when evaporated to dryness. And under
the microscope, organic forms of different kinds were present in abundance, some
of them motionless delicate elongated rods (bacteria ?), others with wriggling
movements, apparently of vibrionic nature, while there were also numerous
amorphous and faint granules, probably also organic. Nine days after the
urine had been placed in the glass, two little woolly balls of fungus were visible
in it to the naked eye. In correcting the proof, I may add that the urine is
now thronged with fungous growths of at least three different species ; while
the odour is highly offensive. But the hot summer weather of the last two
months has produced no change in the contents of either of the flasks with
OF TREATMENT IN SURGERY 57
bent necks.} Observe, then, what inference is to be drawn from this remarkable
fact. There has been nothing in the bent tubes that could by possibility inter-
fere with the transit of any of the gases of the atmosphere. At first, indeed,
they contained some drops of condensed aqueous vapour; but these in a few
days disappeared, the tubes being dried by the air passing through them, and
I beg you particularly to observe that, in the instance before you, the tube is
open and dry from end to end. Every atmospheric gas, therefore, in whatever
proportion it may exist, must have daily passed unchanged into the flasks to
exert upon the putrescible urine any influence of which it was capable; yet
no putrefaction has occurred. The urine has remained absolutely free from
putrefactive changes for half a year, though exposed during the whole of that
time to the action of all the gases of the atmosphere, perpetually renewed.
Surely we are safe in drawing the inference that, in the case of this putrescible
substance at least, the atmospheric gases alone are incapable of inducing
putrefaction. What is it, then, that is essential to putrefaction of urine by
atmospheric influence which the bent tubes have arrested? It cannot be any
of the gases ; but it may be, it must be, some particles suspended in them, some
dust, which the angles of the tubes might arrest mechanically. And this con-
clusion, inevitable as it is from the consideration of the flasks with bent necks,
is confirmed by comparison with the other in which the orifice, though narrower,
was purposely so arranged as to afford a better chance for the introduction of
particles of dust, and in which accordingly chemical changes soon declared
themselves in the contained liquid.
This experiment has an equally clear bearing upon the question of equi-
vocal generation, essentially involved in the germ theory of putrefaction. It
illustrates strikingly what appears to be the truth; namely that even the lowest
and most minute forms of life with which we are conversant, do not arise spon-
taneously in organic substances as the result of the operation of the atmospheric
gases upon them, but take their origin from definite particles or germs, the
offspring of pre-existing organisms. For, on the one hand, we have seen that
this liquid, which is a most favourable nidus for such development, has remained
for half a year free from any change in its appearance such as even microscopic
organisms would produce, though exposed freely during that long period to
the influence of air unchanged except in the circumstance that it has been
filtered of suspended particles. And, on the other hand, this same liquid
similarly situated in every respect, except in the fact that particles floating in
the atmosphere might gain access to it, soon presented, even to the naked eye,
two distinct kinds of vegetation, each springing from a definite point, and grow-
ing steadily from that point, but incapable of taking origin in any other part
58 ONS THE ANTISEPTIC SYSTEM
of the liquid. [The facts subsequently ascertained, of the absence of any living
organism which the microscope could detect in the liquid from one of the flasks
with bent neck, and the speedy appearance of abundance of such minute objects
as well as of others visible to the naked eye, when the liquid had been removed
from its protecting chamber, afford, of course, most satisfactory confirmation. }
There is one circumstance in this experiment which may appear difficult
to comprehend. Admitting that the angles of a narrow bent tube might arrest
the progress of even the finest dust of air when in very gentle motion, is it con-
ceivable that such particles could fail to be driven into the flasks during the
first rush of air into them on the withdrawal of the lamp at the time of the
original boiling ? This difficulty is met by Pasteur in the following way. He
says doubtless germs are carried in, but they pass into a liquid so hot as at
once to destroy their vitality. Now, though I feel much diffidence in expressing
dissent from so high an authority, I must say I do not feel satisfied with this
explanation ; inasmuch as Pasteur has himself related experiments which show
that the mere raising of urine to the temperature of 212° Fahr. is not sufficient
to ensure the destruction of the vitality of the tough-lived germs which it may
contain ; but that it is essential for that purpose to maintain the liquid for some
minutes at the boiling-point.t’ But, if this be so, the germs introduced on the
withdrawal of the lamp, being under the same circumstances as those in urine
simply raised to 212° Fahr., and at once allowed to cool, should retain their
vitality and give rise to organic development. The explanation which has
occurred to myself is as follows. Immediately that the steam ceases to issue
from the tube on the removal of the lamp, moisture is deposited upon its
interior from the condensation of the aqueous vapour in it; and this moisture
remains clinging to the interior of the tube, and tending to form drops at its
angles, however rapidly the air be driven through it. And it seems to me
natural that this water in the tube should arrest the particles in the air trans-
mitted through it. Conversely, I am inclined to think that the germs of the
two growths visible to the naked eye in the flask with straight and short neck
entered with the first rush of air, but retained their vitality in the hot liquid,
as in Pasteur’s experiments with urine heated to 212° Fahr., and at once cooled.
These two fungi had already grown to a sufficient size to be distinguishable by
the naked eye, within a few days of the commencement of the experiment, but
no other points of growth appeared during the ensuing month ; implying that
the germs of such fungi, though admitted at first, when the air entered rapidly,
were excluded by the narrow though straight neck during the slow movements
caused by the gradual diurnal changes of temperature.
’ Comptes Rendus, vol. 1, p. 306.
OF TREATMENT IN SURGERY 59
Believing that there must be germs of various organisms adhering to the
interior of the narrow neck near its orifice, I thought that if I were to seal the
orifice, and then allow some of the liquid to pass up to its immediate vicinity,
I might wash down some of them into the body of the flask, and so induce other
growths in the urine. Accordingly, on the 20th of November, nearly a month
after the commencement of the experiment, I sealed the end of the tube with
the blow-pipe, protecting the neighbouring parts of the neck from the flame
as well as I could with a bit of wet lint wrapped round it. I then tilted the
flask so as to cause some of the urine to pass into the neck and back again ;
and you will observe that there is still a drop in the immediate vicinity of the
sealed extremity. A few days later, I imagined that I had attained my object,
as several minute points of growth were seen upon the surface of the liquid,
distinct from the original floating mass, which by this time had assumed a really
beautiful appearance, its upper surface being a circle of three-quarters of an
inch in diameter, composed of concentric rings of blue mould. But, in the
course of a few more days, it became evident that the new growths were of
identically the same species as the original floating one; and, on the other
hand, that the drop near the end of the neck remained perfectly transparent,
instead of exhibiting fungous developments as I had anticipated. Hence
I inferred that the germs, which I could not doubt must have existed near the
orifice, had been arrested so close to it as to be destroyed by the heat of the flame.
Whence, then, did the new growths in the body of the flask take their origin ?
The answer is obvious enough. The blue mould covering the surface of the
original growth teemed with myriads of sporules of the fungus, and, like larger
plants, was ready to shed its ripe seeds when shaken; and the tilting of the
flask, which had up to that time been carefully kept from disturbance, scattered
some of these ripe germs, which grew into organisms like their parent. About
a month after the sealing of the tube, all further growth of the fungi in the
flask ceased, and its contents have remained unchanged for the last four months,
except that the fungi have become shrunk and unhealthy in aspect. This
I attribute to the cutting off of the supply of oxygen by the sealing of the tube.
[This view has since been verified. On the 2nd inst. (May 1868), I broke off
the sealed end of the neck after scratching it with a file, leaving the flask other-
wise undisturbed. In four days, I detected the first indications of return of
the growth which had been so long suspended; and, a few days later, the
dwindled and discoloured original growths were abundantly covered with fresh
vegetations of the same nature as before, while the surface of the fluid presented
multitudes of new points of development of the same species ; the unavoidable
motion of the liquid in conveying the flask to and from the meeting, which
60 ON TTHE-ANTISEP PIC SYsiiM
indeed greatly marred the beauty of the fungi, having evidently scattered other
germs about, which remained latent till fresh air was admitted. |
Looking at this experiment as a whole, we see that the atmosphere was
rendered incapable of inducing in that specimen of urine either putrefaction
or the formation of even the lowest and most minute known organisms, by
merely depriving it of its suspended particles; or, conversely, that the ‘ air-
dust’ is the essential cause both of organic development and of putrefactive
changes in such a liquid; while the experiment further illustrates what seems
to be a general law; viz. that the low forms of life to which the atmospheric
particles give rise, so far as we are able to observe them, resemble higher plants
or animals in springing only from pre-existing organisms. Any one who bears
these facts in mind will have little difficulty in admitting the truth of the germ
theory of putrefaction ; and I venture to recommend to any of you who may
hereafter feel perplexed by the contradictory and bewildering statements of
various authors upon this subject, and be tempted to regard it as hopelessly
obscure, that he should recall to his memory the clear evidence respecting it
which has been brought before you this evening.
Emphysema and Pneumothorax from Simple Fracture of the Ribs.
This mode of experimenting, as described by Pasteur, besides charming me
by its simplicity and conclusiveness, had a further special interest for myself,
because, before knowing of it, I had explained to my own mind on the same
principle the remarkable fact, previously quite inexplicable, that, in simple frac-
ture of the ribs, if the lung be punctured by a fragment driven inwards upon it,
the blood effused into the pleural cavity from the wound in the highly vascular
organ, though freely mixed with air which enters the pleura through the same
orifice, undergoes no decomposition, as is clearly implied by the absence of any
symptoms of pleurisy in such cases. The air is sometimes pumped into the
pleural cavity in such abundance that, making its way through the wound in
the pleura costalis, it inflates the cellular tissue of the whole body; yet this
occasions no alarm to the surgeon, unless the opening in the parietal pleura
become insufficient to permit free egress for the air, which then becomes pent
up in the serous cavity, and, distending it far beyond its natural dimensions,
encroaches on the other lung so seriously as to embarrass or even abolish its
functions. Thirteen years ago, I had the opportunity of making a post mortem
examination of the body of a man who had died under such circumstances ten
days after the receipt of the injury which caused his symptoms; and I was
much struck to find the enormously distended pleura free from effusion, and
perfectly smooth and healthy. Why air introduced into the pleura through
OF TREATMENT IN SURGERY 61
a wounded lung should have such totally different effects from that entering
through a permanently open penetrating wound from without, was to me a com-
plete mystery till I heard of the germ theory of putrefaction, when it at once
occurred to me that, though we could not suppose the gases of the atmosphere
to be in any way altered in chemical composition by passing through the trachea
and bronchial tubes on their way into the pleura, it was only natural that they
should be filtered of germs by the air-passages, one of whose offices it is to arrest
inhaled particles of dust, and prevent them from entering the air-cells. In
truth, this fact in practical surgery, when duly considered, affords as good
evidence in support of the germ theory of putrefaction as any experiment that
can be performed artificially.
Another remarkable example of the same thing, though brought about by
different circumstances, occurred recently in my practice at the infirmary.
Case of Penetrating Wound of the Thorax and Abdomen.—On the Ist of
October last, a butcher, aged 18, was admitted on account of a most serious
wound of the chest, inflicted by a comrade who, angry at having a dirty bladder
thrown at him by the patient, threw in return his knife, with a blade nine inches
long, and keen-edged, half of which buried itself in the patient’s infra-axillary
region, between the ninth and tenth ribs. He himself drew out the knife,
which was followed by a fearful gush of blood. Being accustomed to see blood
flow, he said ‘ there was a spout of four inches before the fall’. He was im-
mediately taken to the hospital, where my then house surgeon, Mr. Hector
Cameron, found him blanched, his clothes drenched with blood, which was still
pouring from the wound, venous in colour, and with a tendency to regurgitate
during inspiration, implying that it proceeded from a wound in the lung, which
was further indicated by the occurrence of haemoptysis. There was also pro-
truding from the external wound a piece of omentum five inches long, showing
that the knife had passed through the diaphragm into the abdominal cavity.
No time was to be lost, as death from haemorrhage was imminent; and Mr.
Cameron judged it best to plug the wound, but at the same time to introduce
an antiseptic as in compound fracture, in order to destroy any atmospheric
germs that might have been drawn in during inspiration. With this object,
after cutting off the protruding piece of omentum, which he kept to show me,
he soaked a piece of lint with a solution of carbolic acid in four parts of boiled
linseed oil, and by means of dressing-forceps passed it as far as he could in every
direction in the pleural cavity, repeating the application several times. He
then took two strips of lint steeped in the same solution, each about a foot
long and an inch in breadth, and pushed them into the pleura, one upwards,
the other downwards, as far as possible consistently with keeping their ends
62 ON THE ANTISEPTIC SYSTEM
protruding externally ; and, the wound being thus plugged antiseptically, he
applied a sheet of paste composed of whitening mixed with the oily solution
of carbolic acid before mentioned, taking care that it was large enough to over-
lap the skin around the orifice by several inches in every direction, retaining
it in position by strapping and bandage. It may, perhaps, be said by some
of you, ‘Surely it was heroic practice to introduce irritating carbolic acid so
freely into that important serous cavity. Would it not have been a milder
and more prudent course to have plugged the wound with a piece of dry lint ?’
But any one who argues in this way forgets what would have been the inevitable
result of such a procedure. The mass of blood accumulated in the pleura would
necessarily have been soon decomposed through the agency of the germs con-
tained in the lint; and the putrefying mass, growing from day to day more
acrid in the cavity in which it was confined, would undoubtedly have soon
caused the death of the already prostrated patient. On the other hand, carbolic
acid, being a local anaesthetic, is much less irritating, even when first applied,
than the products of decomposition ; and it also differs from the latter in this
all-important point, that it soon becomes dissipated by diffusion and removed
by the surrounding circulation, when, the blood on which it has acted being
still amenable-to organization and absorption, the part is as favourably situated
as if affected only with a subcutaneous injury. Next day, when I saw the
patient for the first time, I cautiously withdrew the plugs, under the protection
of a large piece of lint dipped in the oily solution of carbolic acid, and continued
the use of the paste. For about ten days the patient progressed admirably,
the pulse descending, the laboured rapid respirations growing less laboured
and less rapid, and altogether his condition becoming so much improved that
he could not be prevented from sitting up in bed, singing songs, and conducting
himself otherwise in an imprudent manner. Meanwhile, examination of the
thorax disclosed signs of the presence of both blood and air in the pleura, such
as dullness of the base and preternatural resonance of the upper and anterior
part of that side of the chest, and metallic tinkling, which was well marked.
And to such an extent had this accumulation of blood and air proceeded, that
the heart had been pushed over towards the right side, so that its apex beat
below the right nipple. And yet this mass of blood, freely exposed to the
influence of air, had not decomposed. Any putrefactive germs introduced
through the external wound had been destroyed by the carbolic acid, and the
air, entering the pleura through the wounded bronchial tubes, had deposited
its floating organisms upon the slimy mucous secretion of those tortuous canals.
Hence the patient remained free from any symptoms of irritation, and suffered
only from loss of blood and the embarrassment of the respiration which was
OF TREATMENT IN SURGERY 63
the mechanical result of the injury. But, thirteen days after the accident,
profuse haemoptysis appeared, which I was disposed to attribute to tearing
open of the wound in the lung through his imprudent exertions; and this,
continuing for several days, threatened entirely to exhaust his weakened frame.
The expectorated blood assumed also a putrid odour, like that from gangrene
of the lungs; and I was apprehensive that the putrescence might spread to
the mass in the pleura. Fortunately, however, this did not occur. The bloody
expectoration gradually became purulent, and then diminished in quantity till
it ceased entirely. With regard to the external wound, it furnished no pus so
long as the original mode of dressing was continued. In the first twenty-four
hours, there was a free discharge of bloody serum; but this grew less from
day to day, till, six days after the receipt of the injury, it amounted to less
than a minim in forty-eight hours ; and when the piece of lint, which had been
kept permanently on the wound beneath the paste, was removed, between
three and four weeks after the accident, a superficial sore was found, which
afterwards cicatrized kindly. On the 18th of November, seven weeks after his
admission, the apex of the heart was observed to be again beating below the
left mammilla ; and, finally, I may add, that he was seen a few days ago by
Mr. Cameron, engaged with another butcher in driving a herd of unruly cattle
through the streets, when our former patient, though still pale from anaemia,
proved the more vigorous of the two in turning the animals; while his lusty
exclamations, though not couched in the most decorous language, gave satis-
factory evidence of the soundness of his lungs.
Ligature of Arteries.
I have now to show you a preparation illustrating the effects of the applica-
tion of a ligature upon an artery on the antiseptic system. The theory of such
a procedure is simple. A foreign body introduced among the tissues does not
exert any disturbing influence upon them, unless it be either mechanically or
chemically irritating. Thus, it is well known that a needle or a spiculum ot
glass may lie for an indefinite period embedded in the living textures without
inducing suppuration ; and any irritation which may result is due simply to
the rigidity and form of the foreign solid. Now, a bit of silk or linen thread
being composed of materials of soft consistence and as unstimulating chemically
as glass or steel, its presence among the tissues cannot of itself occasion any
disturbance. But, unlike the glass or metal, the thread is porous, and contains
in its interstices putrefactive germs, which, developing in the serum that bathes
the ligature, give rise to the acrid products of decomposition, and these, in their
turn, stimulate the surrounding tissues to granulation and suppuration. I,
64 ON THE TPANITSEPIIC SYSTEM
however, the thread were steeped in some liquid calculated to destroy the life
of the germs in its interstices, and the wound by which it was introduced were
dressed antiseptically, the ends of the ligature being cut short, it might be left
with confidence that its presence would not interfere with primary union, or
occasion any disorder in the surrounding parts. [The traction exercised on the
external coat by the noose of the ligature is no doubt a temporary cause
of mechanical irritation, but this does not appear to have any considerable
influence.| Before applying these principles upon the human subject, I thought
it right to test them on one of the lower animals.
Ligature of the Carotid Artery in the Horse, on the Antiseptic System.—On
the 12th of December last, I tied the left carotid of a horse about the middle
of the neck, using fine but strong ‘ purse-silk’, unwaxed, but steeped for some
time in a saturated watery solution of carbolic acid. [The product of the action
of carbolic acid upon blood serves the purpose of wax in preventing the first
half of the knot from slipping during the tying of the second half.] The ligature
having been tightly tied, so as to rupture the internal and middle coats, its
ends were cut short, and the wound was freely treated with carbolic acid dissolved
in forty parts of water. Seven stitches of the coarse soft wire used by veterinary
surgeons for the purpose were introduced into the long wound, the most depen-
dent part being left free for the escape of discharge. The hair around the
wound was well rubbed with a solution of carbolic acid in four parts of olive oil,
and cloths saturated with the same antiseptic oil were applied overlapping the
surrounding skin freely, and retained in position by means which I need not de-
scribe ; and similar oil was poured daily upon the cloths for the first six days. Ten
days after the operation I removed the dressings, and found the wound perfectly
united throughout, except at the part purposely left open, which was covered
with a sort of cheesy material, and as each stitch was removed there was absence
of even serous exudation. The wound was now left exposed, and in three days
more the lower part had healed by scabbing, no suppuration having occurred from
first to last. At the same time, there was none of the swelling and induration
that usually attend the application of a ligature to a vessel in the horse’s neck,
and the animal showed no signs of uneasiness when the part was freely handled.
Five weeks and four days after the tying of the artery, the creature, though
it had improved greatly in condition under its superior diet in the veterinary
establishment, died, as the groom believed, of exhaustion from struggling in-
effectually to rise from the recumbent posture. I had thus an opportunity of
inspecting the parts concerned in the operation, some of which are now before
you. In the first place, here is a portion of the skin containing the scar; and
you will observe that it is a perfectly sound linear cicatrix, barely traceable
OF TREATMENT IN SURGERY 65
among the hair. Here is the artery, slit up to show the condition of the interior.
At the cardiac side of the place where the ligature was applied there was, as
you see, an adherent coagulum, an inch and a quarter in length. But at the
distal side there was no adherent clot, doubtless in consequence of the circula-
tion through a large branch, about as big as the human vertebral, which came
off, you will observe, as close to the situation of the ligature as was possible.
The cul-de-sac formed by the distal end, though it showed indications of the
puckering of the divided internal and middle coats, was completely cicatrized,
the smooth lining membrane of the artery being continuous over the irregular
surface. Why it was that the immediate vicinity of so large a branch did not
lead to secondary haemorrhage, was clear from the state of things beside the
ligature, which lay embedded in a firm fibrous structure, with not only no pus,
but no granulations, no softening of tissue around it. The portion of the external
coat included in the noose, though doubtless killed by the violence with which
it was pinched, had not been thrown off as a slough, but, being unstimulating,
because undecomposing, it had been absorbed and reproduced by the living parts
near it; while the thread had been bridged over externally by dense fibrous
tissue, so that the vessel showed but little appearance of constriction where it had
been tied, and it appears to be as strong at this part as at any other. You may
form some estimate of its strength from the manner in which it resists the traction
to which I now subject it. Here is the ligature with its short cut ends, apparently
unchanged, except that it was divided in my search for it in its fibrous bed.
This case confirms the hope I ventured to express at the meeting of the
British Medical Association in Dublin last autumn,’ that the antiseptic system
would free the deligation of a large artery in its continuity of the two essential
elements of danger to which it is now liable, viz. an unhealthy condition of the
wound, and secondary haemorrhage. Thus encouraged, I felt justified in
carrying a similar practice into human surgery.”
The success of these cases of ligature depends, as we have seen, upon the
circumstance that not only a neutral foreign body, but a portion of dead tissue,
if simply protected from putrefaction, is entirely devoid of irritating properties.
A good example of this fact is presented by a case at present under my care.
Case of Acute Necrosis treated on the Antiseptic System.—The patient is
a boy, eight years of age, who was admitted into the infirmary on the 25th of
January, 1868, having, five days previously, received a violent blow upon the
' See p. 45 of this volume.
* The first part of the report of the case of Ligature of the External Iliac Artery, the first of that
nature to which the antiseptic system was applied, was here given, but has been omitted, being inserted
at the proper place in the next paper, ‘Observations on Ligature of Arteries on the Antiseptic
System’ (see p. 88).
LISTER II F
66 ON THE ANTISEPTIC SYSTEM
left leg with a heavy pair of tongs, resulting in intense inflammation in the
limb, which was red and swollen from the knee to the ankle. Fluctuation
being distinctly perceptible over the upper part of the tibia, the matter was
evacuated antiseptically. A piece of lint dipped in an oily solution of carbolic
acid having been laid upon the part where the incision was to be made, its lower
edge was raised to allow a knife smeared with the same solution to be plunged
into the cavity of the abscess, when the curtain was at once dropped so that
the pus might flow out beneath it. When all the matter had been pressed out,
an external antiseptic dressing was applied, and this was afterwards changed
daily. Four other abscesses afterwards made their appearance at intervals
down the limb. These were treated in the same way ; and in every case when
a probe, carefully guarded by being passed among folds of lint steeped in the
antiseptic oil, was introduced into the incision, it came into contact with bare
bone. This was of itself sufficient evidence that portions of the tibia, of greater
or less thickness, were dead ; for, had the periosteum been raised by suppuration
from living bone, the osseous surface would have become covered with granu-
lations during the process. But evidence which must satisfy the most incredu-
lous is afforded by the fact that, between two and three weeks after the first
abscess was opened, a probe introduced into the orifice still passed down to
bare bone. Under such circumstances, what, it may be asked, could be the
advantage of continuing the antiseptic dressing? If dead bone was present,
whether in larger or smaller amount, must it not become detached from the
living osseous tissue by a gradual process of exfoliation, which an antiseptic
applied to the skin could neither promote nor hinder?) Such may be a natural
inquiry. But having seen a large mass of dead bone absorbed before my eyes
by the granulations that enveloped it, in a case of compound fracture treated anti-
septically'; and having also had evidence from post mortem examination in a case
of hip-joint disease where extensive necrosis existed in connexion with caries, that
bone killed by inflammation might, under antiseptic management, fail to induce
suppuration ; putting those facts together, I thought it not unlikely that, in the
case we are considering, the dead portions of the tibia would be absorbed by the
living tissues around them, if we perseveringly maintained an effectual external
antiseptic guard. Such, then, was the practice we pursued, and the result was
such as I had anticipated. The various incisions successively healed, till by the
6th of April, eleven weeks after the receipt of the injury which caused the attack,
the abscess last opened was soundly closed and cicatrized, not a particle of dead
bone having come away from any of the openings. At the same time, the swelling
of the limb, instead of increasing, as is the case under ordinary treatment, from
* See p. 16 of this volume.
OF TREATMENT IN SURGERY 67
formation of new bone in the periosteum under the stimulating influence of exfolia-
tions soaked with putrid liquids, had disappeared almost entirely from the upper
part of the leg, which was that primarily affected, and was rapidly diminishing
elsewhere. [On the 18th of May, the boy left the hospital with the full use
of the limb. I had intended giving him a somewhat longer rest in bed as a
measure of precaution. But I found that for a considerable time it had been
impossible to keep him from getting up and running about the ward; and
he was none the worse for his activity.] This certainly was very different from
the tedious course of such cases under ordinary treatment.
With regard to the manner in which the dead bone has been disposed of,
some who have not witnessed similar occurrences may doubt the possibility
of its absorption, and believe that the necrosed pieces are still lying unchanged
in the interior of that leg. But even those who take such a view must admit
that we have here a most striking illustration of the important truth, that dead
tissue, if protected from putrefaction, is of itself incapable of exerting any
disturbing influence upon surrounding parts.
Carbolic Dressings.
I will now proceed to speak of the mode of dressing. Carbolic acid, as
I have already remarked, is soluble in liquids of very different kinds, so different,
for example, as water and one of the fixed oils ; and each solution has its own
special value. Water, having little affinity for the acid, dissolves but a small
quantity, only one-twentieth part of the pure crystals,’ and holds that small
quantity very loosely, so as to permit it to act with energy on any substance
for which it has stronger attractions, and also to become soon dissipated on
exposure. Hence, the watery solution is a pretty potent but transient applica-
tion. Now this is exactly what we want when we apply carbolic acid to the
interior of a wound for the purpose of destroying any germs which may have
been introduced into it. We require something that will act with energy for
the moment ; but which, as soon as it has extinguished the vitality of the septic
particles, may disappear from the wound, in order that the tissues may be left
free from all unnecessary irritation. The fixed oils, on the other hand, have so
strong an affinity for the acid that they will mix in any proportions with it,
and hold it so firmly as not to permit it to act with much energy on the tissues,
* The impurities often met with in carbolic acid interfere with its solubility in water. The first
specimen with which I happened to experiment was an impure liquid kind, sold as ‘ German creosote’,
and this was absolutely insoluble in water; the associated organic compounds having, apparently,
too strong an affinity for the acid to permit water to appropriate any of it. I was thus led into the
mistake of stating that carbolic acid is insoluble in water (see note on p. 4 of this volume). I may remark
that the public are much indebted to Mr. Crace Calvert, of Manchester, for his successful efforts to pre-
pare carbolic acid in a pure form at a moderate price.
F2
68 ON THE ANTISEPTIC SYSTEM
or to become soon dissipated into the atmosphere. Hence an oily solution is com-
paratively bland but permanent in its operation. These are just the properties
which are desirable for an external application. We wish it to serve as a reser-
voir of the acid, retaining it for twenty-four hours at least, so that it may remain
constantly exerting its antiseptic influence upon the discharges that flow out
beneath it. At the same time it is most important that it should be mild in
its action on the surface to which it is applied, in order to avoid irritation and
excoriation. It appears clear, therefore, that a watery solution is best adapted
for the treatment of the interior of a wound in the first instance, while an oily
preparation is suited for an external dressing.
We have next to consider the best form for the oily application. I have
used various forms ; of which some have proved trustworthy, and others not
so. One that has shown itself thoroughly reliable is a paste composed, like
glazier’s putty, of boiled linseed oil and whitening, but with the addition of
about one part of carbolic acid to four of the oil. Even in the case of large
abscesses, where there has been in the first instance a profuse discharge, the
putty, if properly applied and retained securely in position, prevents with perfect
certainty the spread of putrefaction into the interior. But the putty is a some-
what clumsy and inconvenient preparation, and I have been desirous, if possible,
to get rid of it. Within the last few months I have given a full trial to cloths
dipped in a solution of carbolic acid in olive oil, but I am sorry to say that this
method, though attractive from its simplicity, is not reliable. It is true, indeed,
that we have had some beautiful cases under this mode of management; as
for example the following.
Case of Compound Fracture of the Right Leg and Severe Contused Wound
in the Left Foot, in a Person of Advanced Age.—On the 31st of January last,
a woman, aged seventy-four years, was admitted into the infirmary, having
been run over by a heavily laden omnibus. The wheels had passed over both
lower limbs, producing in the right leg compound fracture of both bones a little
above the ankle, with a considerable wound on the outer side of the limb com-
municating with the broken fibula, and another on the opposite aspect, not
directly connected with the seat of fracture. In the left limb the violence had
been sustained by the foot, which presented at its inner aspect a large gaping
contused wound, four inches long and two inches broad, while the skin was
extensively detached, so that when a watery solution of carbolic acid had been
introduced at the wound, pressure over the skin at the outer, or opposite side
caused some of the fluid to escape, showing that it had passed freely over the
upper surface of the foot, beneath the undermined integument. She had also
a wound on the forehead, two inches long, exposing the os frontis. From these
OF TREATMENT IN SURGERY 69
various injuries she had lost a great deal of blood, and she was also suffering
from contusions in other parts of the body. All the wounds were dressed with
layers of lint soaked with a solution of carbolic acid in olive oil ; the superficial
layer, larger than the rest, being changed daily while the deeper layers were
left undisturbed. Under this treatment the wound on the forehead healed
without the formation of a drop of pus, and those in connexion with the com-
pound fracture were converted into superficial granulating sores, without any
more disturbance, local or constitutional, than if the fracture had been a simple
one ; and the bones united in the usual period under the use of pasteboard splints.
But the most remarkable circumstance in the case was the progress of the injury
of the foot. Three days after the accident, my house surgeon, Mr. Appleton,
observed that a considerable portion of the undermined skin on the dorsum
of the foot had lost its vitality ; and instead of adopting the usual course of
applying wet lint or a poultice till the slough should separate, he extended the
antiseptic dressings so that they overlapped the dead portion of tissue for a con-
siderable extent in every direction; after which, the daily changing of the
superficial layer was continued as before. The result, though in strict accor-
dance with the principles which I am endeavouring to enforce, was strikingly
opposed to ordinary experience. After the subsidence of the copious sanious
effusion which took place immediately after the injury, the discharge became
reduced to about one minim in twenty-four hours, without any distinct appear-
ance of pus, while the foot remained free from the slightest uneasiness, so that
she moved it as usual in the bed, and imagined it perfectly recovered. Such
being the case, knowing, as I did, that to remove the deep dressings would be
to induce, at the best, two large granulating sores which must, from that time
forward, furnish a considerable amount of pus that would act as a drain upon
the old lady’s feeble system, I left the crust of lint and dried exudations untouched
for seven weeks, at the end of which time it became spontaneously detached.
On raising it, we found a narrow line of cicatrix along the inner side of the foot,
complete healing by scabbing having occurred in, I suppose, the largest wound
ever known to heal in that manner in the human subject. And on the dorsum
of the foot, in place of the large slough, was a broad scar, a portion in the centre
about as large as a fourpenny-piece alone remaining unhealed ; the dead tissue
having, apparently, been absorbed, as none of it was found on the dressing.
The superficial layer of antiseptic lint, daily renewed, had answered the purpose
of preventing putrefaction from spreading inwards, while the thickness of the
permanent crust had kept the carbolic acid constantly supplied externally from
penetrating to its deepest parts. Hence, the portion of the dressing in contact
with the skin, having lost its original acid by diffusion into the circulation,
70 ON THE ANTISEPTIC SYSTEM
before sufficient time had elapsed for granulation and suppuration to take place
under the stimulating influence of the antiseptic, became a perfectly unirritating
or neutral body, and the dead portion of tissue beneath it, being in like manner
destitute of any stimulating properties, became amenable to absorption, like
the bit of the external coat in the noose of the antiseptic ligature, or the dead
bone in the case of necrosis, above related.
But, while I have mentioned this case as a good example of the behaviour
of severe injuries under antiseptic management, I wish it to be distinctly under-
stood that I do not recommend the mode of dressing adopted. For, as I have
already stated, and as bitter experience in some other cases has but too clearly
convinced me, it cannot be implicitly relied on. The reason why it 1s less trust-
worthy than the putty is sufficiently plain. The lint, being porous, absorbs the
discharge, which, as it enters, displaces the antiseptic oil, and may thus, if
profuse, establish a channel of putrescible materials from the external atmo-
sphere to the wound. Again, when the discharge has passed through the dress-
ing, even though it have been imbued with carbolic acid in its passage, it gives
it off into the atmosphere on exposure, when it becomes again liable to putre-
faction, and, having putrefied, may soak back into the porous dressing, and
deprive it entirely of antiseptic virtue. For carbolic acid and the products of
putrefaction exert a powerful chemical action upon each other; and, on this
account, the former is a deodorant as well as an antiseptic, and, conversely,
the latter, if in sufficient. quantity, neutralize the acid and render it inert. In
this way, I have known a dressing, consisting of several layers of the oiled lint,
lose all odour of carbolic acid and acquire that of decomposition within twenty-
four hours of its application.’ The putty, on the other hand, being impermeable
to the discharge, retains the carbolic acid securely stored up, except in so far
as it is exhaled from the surface, to maintain a constant antiseptic action upon
the blood, serum, or pus that flows out beneath.
Impermeability to a watery fluid being thus evidently the essential cause
of the superior efficacy of the putty, the chalk, which is its chief constituent,
being of no other use than to give consistency to the mass, it naturally occurred
to me that, if the oily vehicle of the carbolic acid were in a solid form, the chalk
might be dispensed with, and the advantages of the putty might be obtained
in a less bulky and more convenient form. I tried, in the first place, various
* If fresh oil is assiduously supplied at short intervals by night as well as by day, this objection
to oily cloths as a dressing is removed. But this would in many cases be impracticable; and, as a
general rule, it is obviously undesirable, from the trouble and uncleanliness involved in it. There are
situations, however—such as the perineum—in which this is probably the best mode of management.
And it may be added that, in any case where the discharge is very trifling, oiled lint, changed once in
twenty-four hours, will prove sufficiently reliable.
OF TREATMENT IN SURGERY ae
kinds of emplastva; but these appeared objectionable on account of their ad-
hesiveness, which is greatly increased by the admixture of carbolic acid, and
' which seemed likely to be mischievous by retaining the discharge. I next
employed paraffin, mixed with a little wax to give it tenacity, and a little
olive oil to confer the requisite softness. This certainly made, under ordinary
circumstances, an effective as well as elegant substitute for the putty, being
perfectly devoid of adhesiveness, while a comparatively thin layer proved
securely antiseptic. But the paraffin cerate had this great disadvantage,
that, in situations where it was subjected to much movement, such as the groin,
it was apt to crumble down and become useless. Meanwhile I learned that
Dr. Watson, of Edinburgh, was employing soap-plaster mixed with carbolic
acid, and that, though adhesive, it appeared to work well ; the discharge finding
its way out beneath it. Thus I was again induced to try emplastra ; and of late
we have been using what seems to answer admirably, namely emplastrum plumbi
mixed with one-fourth part of bees-wax to give it sufficient consistence, the
carbolic acid being in the proportion of about one-tenth of the whole.?. This is
used as a plaster spread on calico in a layer of about one-twentieth of an inch
thick, and I can recommend it as thoroughly reliable. There is a case which
I am dressing with it at the present time, which I may mention on account of
its interest otherwise.
Case of Old Fracture at the Ankle with Fixed Displacement of the Foot, Rectified
‘ In making the plaster with the ingredients mentioned in the text, the emplastrum plumbi and
the bees-wax are melted and mixed together, and allowed to cool, till the liquid begins to thicken ; the
carbolic acid is then added and stirred in, which has the effect of bringing back the mass into the state
of a thin liquid, which is assiduously stirred till it thickens, to prevent the wax from separating in
granules. This plaster is, however, inconveniently soft, and cannot be kept spread in stock. I have
since found that by increasing the proportion of litharge, the lead soap may be made of any degree
of firmness that may be desired, provided that water be not used in the manufacture. When the
litharge and olive oil are in the proportions directed by the Pharmacopoeia, a certain quantity of water
must be added to promote the combination of the fatty acids with the oxide of lead, and even then the pro-
cess is avery tediousone. Butit isan interesting fact chemically, that if the litharge is used in about four
times the pharmacopoeial proportions, although no water be employed, the combination proceeds under
a brisk heat with great rapidity. It is upon this fact that the following method of manufacture is based:
Take of olive oil, 12 parts by measure; litharge (finely ground), 12 parts by weight ; bees-wax,
3 parts by weight; crystallized carbolic acid, 2} parts by weight. Heat half the oil over a slow
fire; then add the litharge gradually, stirring constantly till the mass becomes thick or a little stiff.
Then add the other half of the oil, stirring as before till it becomes again thick. Then add the wax
gradually till the liquid again thickens. Remove from the fire and add the acid, stirring briskly tll
thoroughly mixed. Cover up close and set aside, to allow all the residual litharge to settle ; then pour
off the fluid, and spread upon calico to the proper thickness. The plaster made in this way can be
spread by machine, and kept rolled up in stock; and, if in a well-fitting tin canister, will retain its
virtues for any length of time. This I believe to be the most perfect form in which an antiseptic lead-
plaster can be obtained. For almost all purposes, however, it is superseded by the lac-plaster, which
will be found described in the succeeding part of this address. These improvements in the materials for
dressing have occupied a much longer time than I had anticipated ; and have been the cause of the
delay in publication.—J. L.
72 ON THE ANTISEPNC SYSTEM
by Atd of the Antiseptic System.—A young man, aged twenty-nine, was engaged in
mooring a vessel on the 11th of December, 1867, when one of the massive ropes,
used for the purpose, slipped and struck him with violence at the outer and
posterior aspect of the ankle, fracturing the fibula about two inches above
the joint, and breaking off the internal malleolus at its base, driving the bones
of the leg forwards and inwards with respect to the foot, or, in other words,
producing displacement of the foot backwards and outwards. Four months
after the receipt of this injury he came under my care in the infirmary, with
the heel very prominent and the foot greatly everted, and firmly fixed in its
abnormal position by osseous union of the fragments. In this condition the
limb was absolutely useless, and the question arose whether anything could
be done to restore it. It was clear that the foot could not be replaced without
breaking through the ‘ callus’ which could be plainly felt in both bones, and
there seemed no prospect of being able to do this without cutting down and
adopting means which, in the case of the tibia, would necessarily involve opening
into the articulation, or producing artificially a compound fracture into the
ankle-joint. This I certainly should not have dreamed of doing without the aid
of the antiseptic system, being well aware of the disastrous course such injuries
commonly run under ordinary management. If I had operated at all, I should
have made a point of removing the end of the tibia, and even then I should
have felt that I was subjecting the patient to some risk. But feeling confident
that I had the means of converting a compound fracture into a simple one,
I did not hesitate to adopt the following procedure. On the r1th inst. (April
1868), the man being under the influence of chloroform, I made a curved incision
behind and below the prominent end of the tibia ; and, a solution of carbolic
acid in about four parts of olive oil being dropped into the wound during the
progress of the operation, I detached the soft parts from the bone sufficiently
to enable me to insinuate behind the callus one blade of a pair of cutting pliers,
smeared with the same oil, and then having placed pieces of lint, soaked with
the oil, around the blades of the pliers, so as to prevent the chance of septic
air entering the joint when the bone should give way, divided the callus, and
at once covered the wound with the antiseptic lint. I then made a longitudinal
incision over the seat of fracture in the fibula, and divided it with similar
precautions. Having thus overcome the obstacle presented by the bones,
I proceeded to draw the foot towards its proper position by pulleys acting upon
its outer and posterior part through the medium of a skein of worsted passed
round it, while a padded belt supported the opposite aspect of the leg above
the ankle: the wounds being kept carefully covered with the oiled lint. When
a considerable amount of force had been used there was a sudden sensation of
OF TREATMENT IN SURGERY 73
something giving way ; and now, on removing the apparatus, the foot was found
to have resumed its natural place. The wounds were then dressed with layers
of lint soaked with a weak oily solution of carbolic acid, and covered with the
antiseptic plaster ; after which, a Dupuytren’s splint was applied at the inner
side of the limb to prevent eversion, and Mr. Syme’s horseshoe splint anteriorly
to obviate the tendency to displacement backwards. [Fresh plaster has since
been applied daily ; and the result has been that, while the foot has retained
its position satisfactorily, the patient has not suffered at all either locally or
constitutionally, during the six days that have elapsed since the operation.
His pulse has remained 68 or 70, he has not lost his sleep a single night, his
tongue has been quite clean, and his appetite good. In fact, he has taken his
food with better relish than before, because he has been freed from his previous
gloomy prospect of hopeless lameness, while the operation has caused him no
anxiety ; as the assurance which I felt justified in giving him, that it was entirely
free from danger, has been confirmed by the absence of pain or other annoyance.
The discharge, which was sanious and copious in the first instance, has of late
been only about three minims of clear serum in twenty-four hours ; and judging
from our previous experience with compound fractures, there is every reason
to expect that in a few days more it will cease entirely.
[The subsequent progress of the case has been, on the whole, very satis-
factory. But, for reasons to be soon referred to, healing by scabbing did not
take place as was anticipated. The discharge, instead of drying up, showed
rather a disposition to increase, and assumed a somewhat puriform character ;
and, although the renewal of the superficial plaster once in two or three days
did not involve much disturbance of the limb, I thought it best to expose the
wounds when sufficient time had passed to ensure the secure coalescence of
their deeper parts. Accordingly, on the 1st of May I removed the lower portions
of the dressings, disclosing two superficial granulating sores, with very prominent
granulations, which explained the want of disposition to cicatrize. These,
though treated with astringents, proved rather indolent, so that they were
not completely healed till the 4th of June, though the bones were firmly united
a fortnight before. .
When he was allowed to walk, though he placed the sole fairly on the
ground, he experienced inconvenience from a contracted state of the sural
muscles, produced by the long-continued displacement of the foot backwards
and consequent downward pointing of the toes, so that he could not bend the
ankle beyond the right angle at which it had been maintained since the operation.
I hoped that this inconvenience would be overcome by exercise ; but in this
I was disappointed ; for though his power of walking improved, it was by no
74 ON “THE VANTTSEP#SIC SYSTEM
means satisfactory. It also appeared that the abnormal position of the foot
had led to an exaggeration of the curve of its arch, to such an extent as to make
the foot half an inch shorter than the other, while the plantar fascia was felt
as a rigid band. I therefore divided that fascia and the tendo Achillis sub-
cutaneously on the 26th of July, and this had the immediate effect of restoring
the foot to its natural length, and permitting the ankle to be bent at an acute
angle. Had I the case to treat over again I should perform the tenotomy at
the same time as the main operation. But except the loss of time that has
occurred, the result is nearly all that could be wished. Under the use of a
Scarpa’s shoe he has continued to improve steadily, and when I last saw him,
in the early part of September, he could walk firmly and well, and complained
only of some remaining stiffness of the ankle.] *
In compound fracture, as a general rule, healing by scabbing is that which
should be aimed at. When this is attained, the treatment becomes greatly
simplified ; while the patient is saved any drain upon the system from purulent
discharge, and any risks that may attend the presence of a granulating sore.
With this object in view, it is necessary that the deeper layers of the dressing
should be left to form the scab, and that, while the antiseptic is renewed from
time to time externally, it should not penetrate to the surface of the wound ;
otherwise the carbolic acid will stimulate the tissues to granulation and
suppuration, though without putrefaction.
But, it may be asked, Is it not objectionable to keep the wound perma-
nently covered up? Is it not desirable to examine it from time to time, and
ascertain what is going on in it? To this I would reply by another question.
Does the surgeon think it needful, in a case of simple fracture, to make an in-
cision and investigate the state of the broken bone, the torn muscles and fasciae,
and the other elements of the contused wound which, though the integument
remains entire, exist as surely as in a compound fracture ? No surgeon would
think of such a course. And, on the same principles, provided no unfavourable
symptoms are present, we may be well pleased to leave the deep portion of the
dressing to serve as a temporary skin.
Yet it must be admitted, that to change the superficial layer of the dressing,
without raising the deeper layers, is often a matter of great nicety, while the
admission of septic air beneath the scab would be fatal to this mode of treat-
ment. For, the dressing being purposely so arranged that the parts in im-
* The Address as actually delivered continued the discussion of the principles of the dressing, and
gave details of the mode of procedure, supposing the lead-plaster to be employed in the form in which
it was then described. In order to enable me to introduce subsequent improvements, I have thought
it best entirely to remodel the remainder, though retaining to a certain extent its original features.— J. L.
OF TREATMENT IN SURGERY 75
mediate contact with the wound may be free from carbolic acid, receiving none
from without to compensate for loss by absorption of that which they originally
contained, the lower surface of the application becomes, in a day or two, devoid
of all antiseptic properties, and the penetration of living germs beneath it would
lead to putrefaction there, which would spread to any extravasated blood or
dead tissue that might remain unabsorbed in the wound. Rather than run
any serious risk of such an occurrence, it would be far better to change the
whole dressing every day. For although this would necessitate granulation
and suppuration, through the continued action of the acid upon the raw surface,
yet the essential object of the antiseptic treatment would be attained; that
object being not the avoidance of suppuration, but the prevention of putre-
faction in the wound. It is of great importance to bear in mind this distinction,
which, from want of clear ideas regarding the conditions which determine sup-
puration, is very liable to be overlooked. A patient may die of poisoning and
irritation in compound fracture, from putrefaction of the blood extravasated
in the limb, before sufficient time has passed for any pus to be formed; and,
on the contrary, suppuration may take place in connexion with compound
fracture, whether from the action of the stimulating antiseptic on the wound
or from the occurrence of abscess in the contused limb independently of atmo-
spheric influence, without the patient’s life being at all endangered, provided
always that antiseptic treatment is perseveringly continued.
Nevertheless, the advantages of healing by scabbing are so great that it is
worth while to endeavour to attain them, and I have been long striving to improve
the method of dressing, so as to get rid, if possible, of the attendant risk. A plan
which has, in most cases, answered well when the putty has been used, is to
make the permanent dressing of two or three layers of lint somewhat larger
than the wound, wrung out of a pretty strong solution of carbolic acid in oil,
say one of acid to four of oil, and covered with a piece of oiled calico or linen
rag extending about an inch beyond the lint in every direction. Over this is
applied a stratum of antiseptic putty, which is changed daily, or once in two
days, according to the amount of discharge. The blood from the wound soaking
into the lint is acted on by the carbolic acid, and changed into a firm substance
which consolidates the deep dressings into a crust or scab, and this crust, while
sufficiently thick over the wound to prevent the carbolic acid of the putty from
penetrating to the raw surface, is so thin at its margins formed by the rag as
to be there kept antiseptic through and through. Then, in changing the putty,
the first thing seen on lifting up its edge is the thin margin of the calico; and
even if this be accidentally raised a little, its antiseptic property prevents any
mischief from resulting. The putty is spread on calico, and the calico is applied
76 ON THE ANTISEPTIC {SYSTEM
next to the deep dressing, to prevent adhesion, while the external surface of the
putty is covered either with thin block-tin or sheet-lead, or, what more recently
we found to answer quite as well, gutta-percha tissue, which, though it permits
carbolic acid to escape through it, is not objectionable on that account if the
putty be sufficiently thick, while the gutta-percha, like the metallic plate, pre-
vents the putty from becoming dry and hard. The putty is made to overlap
the permanent dressing well on all sides, and I may remark that, whether the
impermeable antiseptic guard be composed of putty or not, it is of the utmost
importance that it should extend freely beyond the source of the discharge
in every direction, so that the putrescible fluid may have to flow for some dis-
tance beneath it before it reaches the atmosphere or any dressing containing
active putrefactive organisms. The degree of overlapping of the crust by the
external dressing must vary according to the amount of discharge which may be
anticipated. When this is large, it should be to the extent of three or four
inches. Failures have undoubtedly often occurred for want of attention to
this essential point.
But though this method will, with proper care, generally succeed,! it would
be very desirable, if possible, to get rid of the trouble involved in it. At one
time I hoped this might be done by means of the plaster above mentioned, by
employing a layer of it instead of the calico as the upper part of the permanent
dressing, so that the adhesiveness of the emplastrum might keep the whole
deep dressing securely applied to the skin, except at limited spots where the
discharge might ooze out; another layer of plaster being used instead of the
putty, with calico moistened with a watery solution of the acid interposed to
prevent adhesion of the two layers of plaster. My anticipations, however,
have not been verified in this respect. For the plaster, though it answers
extremely well for an external antiseptic guard, whether in compound fracture,
incised wounds, or abscesses, has proved unsuitable for the permanent dressing.
The substance of the emplastrum becomes softened by the solution of carbolic
acid used to moisten the calico, and permits it to enter beneath it and soak
into the lint below, and stimulate the raw surface to granulate and suppurate,
and this was what occurred in the case of displaced foot above mentioned.
At the same time the lint is kept moist, instead of forming a dry crust, and
hence it may gradually shift its place along with the plaster that covers it,
involving the risk of leaving the wound insufficiently overlapped, if not exposed.
‘ For an admirable example of success with this method, the reader is referred to the Lancet,
August 29, 1868, where Mr. Cresswell, of Merthyr Tydvil, reports a case of gunshot-wound of the
femur, shattering the trochanteric region and neck of the bone; the wound by which the ball entered
posteriorly and that in the groin by which it was extracted by incision, both healing completely by
scabbing, under a crust of oiled lint, covered with antiseptic putty, daily renewed.
OF TREATMENT IN SURGERY 77
I have experienced this inconvenience in two cases of compound fracture which
have been treated in this way. One of these was an old lady, of seventy-five, in
whom the os humeri was severely comminuted just above the elbow-joint, with
a considerable wound from which six loose fragments were extracted; the
other was a boy, twelve years old, whose right thigh was much contused as well
as broken by machinery. These cases, indeed, have done well ; osseous union
having occurred as early as if the fractures had been simple ones. But in both
of them the wounds healed by granulation instead of by scabbing.
With the view of getting over these difficulties I sought to obtain some
kind of antiseptic cement, by which a portion of dressing might be glued down
firmly upon the skin. Among other materials I tried shellac, and, in so doing,
I accidentally hit upon a substance which appears preferable to the plaster for
almost every purpose. I found that this resin could be mixed with carbolic
acid in any amount by aid of heat, the result, when cooled, varying, according
to the quantity of the acid, from brittleness to fluidity, the intermediate pro-
portions giving a firm but flexible solid with a certain degree of elasticity,
approaching to some extent the characters of caoutchouc. It further turned
out that the lac thus associated with the carbolic acid retained it with great
tenacity,’ so that a thin layer spread on calico may be used to store up a large
quantity of the antiseptic, forming an application which retains its virtues for
days at the temperature of the body, and, at the same time, fails to irritate the
skin. It has also this great advantage over the lead plaster, that it cannot
be softened by either a watery or an oily fluid. The only imperfection which it
appeared to show, when used in practice as an external antiseptic guard, was
that when long applied to the skin it adhered to the surface, whereas it is desir-
able that such a dressing should adhere very slightly if at all. This objection
to it I attempted to obviate by spreading it upon gutta-percha tissue, which,
though insoluble in carbolic acid, allows it to travel through its substance. The
lac when thus lined with gutta-percha proved none the less efficient as an anti-
septic, and, being perfectly devoid of adhesiveness and of smooth surface, shed
the discharge in a most perfect manner, greatly excelling, in this respect, the
lead-plaster. But it had one fault, viz. that when subjected to much bending,
as at the fold of a joint, the gutta-percha cracked and admitted the discharge,
which, gradually insinuating itself, detached the gutta-percha more or less
extensively, and introduced an element of risk through the interposition of
a layer of liquid between the antiseptic lac and its lining. This fault has been got
rid of by reducing the gutta-percha to a mere film, incapable of affording lodge-
1 In this respect, lac differs altogether from india-rubber, which, though it may be impregnated
with the acid to any degree, parts with it rapidly.
78 ON THE ANTISEPTIC SYSTEM
ment for fluid, by brushing over the antiseptic lac with a weak solution of gutta-
percha in bisulphide of carbon, which, rapidly evaporating, leaves a coating
of microscopic thinness, yet effectual for preventing adhesion. We have now
given this lac dressing a sufficient trial in wounds and abscesses to entitle me
to recommend it with confidence.'
For an antiseptic dressing that is intended to be changed from time to
time, perfect absence of adhesiveness is a most valuable property ; not only
because it permits all discharge to escape beneath it into the porous material
placed outside to absorb it, but because it avoids traction upon any deeper
dressing or upon the skin during the process of withdrawing it, with the con-
comitant risk of regurgitation of air or liquid charged with living putrefactive
organisms.
But for the permanent dressing in compound fracture this complete want
of adhesiveness is the converse of what we desire. Here, the material employed,
being designed to form part of the scab, should stick to the skin or to anything
else that lies beneath it. The lac prepared as above described may, however,
be readily made suitable for this purpose, by rubbing off the film of gutta-percha
by firm friction with a dry cloth, and then brushing the surface over with liquid
carbolic acid. It then, at once, assumes a sufficient degree of adhesiveness.
In order to ensure healing without suppuration, it is requisite, as we have
seen, not only to prevent the spreading of putrefaction into the wound, but
also to protect the raw surface from perpetual stimulation by the carbolic acid.
In the mode of dressing, above described, in which the putty was employed,
the latter object was attained by means of layers of lint forming a crust too
thick to be penetrated by the acid supplied externally ; and the same plan
would, no doubt, succeed as well with the lac. But to trust to the mere thick-
ness of a penetrable crust is not altogether satisfactory. It would clearly be
better, if possible, to protect the exposed tissues from the stimulating antiseptic
in the lac by a layer of some substance chemically impermeable to carbolic acid.
A metallic plate possesses this property ; and in its more flexible forms, such
as thin block-tin or sheet-lead, it seems likely, at least in ordinary cases, to
+ This plaster is supplied at a very moderate price by the New Apothecaries’ Company, Glassford
Street, Glasgow, to whom I am much indebted for the interest and pains they have taken in bringing
it to perfection. The following is the mode of its manufacture: Take of shellac, 3 parts; crystallized
carbolic acid, 1 part. Heat the lac with about a third of the carbolic acid over a slow fire till the lac
is completely melted ; then remove from the fire and add the remainder of the acid, and stir briskly
till the ingredients are thoroughly mixed. Strain through muslin, and pour into the machine for spread-
ing plaster ; and, when the liquid has thickened by cooling to a degree ascertained by experience, spread
to the thickness of about one-fiftieth of an inch. Afterwards, brush the surface of the plaster lightly
with a solution of gutta-percha in about thirty parts of bisulphide of carbon. When the sulphide has
all evaporated, the plaster may be piled in suitable lengths in a tin box without adhering, or rolled up
and kept in a canister.
OF TREATMENT IN SURGERY 79
answer well. I have, as yet, only had opportunity to try this method in two
cases, but both of these have presented points of interest which make them
deserving of mention.
Case of Contused Wound treated with Block-Tin and Antiseptic Lac.—The
first was a contused wound, three inches long, over the lower part of the tibia,
with some undermining of the skin, in a young man of twenty, occasioned by
the limb being violently squeezed between a heavy iron pipe and a fixed piece
of machinery. Happening to be at the infirmary soon after his admission,
I dressed the case myself, washing and syringing out the wound with a saturated
watery solution of carbolic acid, and covering it with a well-fitting piece of thin
block-tin of rather larger size, washed with the watery solution, and then apply-
ing a piece of lac-plaster, deprived of its gutta-percha layer, overlapping the
tin freely on all sides. A piece of calico was placed outside the lac-plaster, to
prevent adhesion of its edges to a dry cloth, which was wrapped round the leg
to absorb discharge, and was intended to be changed. Next day there was
a good deal of sero-sanguineous effusion on the cloth, for which another was
substituted, moistened with a solution of carbolic acid in four parts of olive oil.
The same was afterwards done daily ; the discharge diminishing rapidly, and
the limb remaining free from swelling or pain, and the constitution from dis-
turbance, till, on the fourth day, the patient, who was a silly youth, was seized
with a desire to see the injured part, and tore off all the dressings. This foolish
proceeding on his part gave us the opportunity of making an interesting obser-
vation. The wound was found perfectly level with the general surface of the
skin, being filled with a clot of smooth surface corresponding to that of the tin
which had covered it, while the edges of the skin were pale and natural in appear-
ance. The dressing was re-applied as before, the wound being superficially
washed with carbolic acid lotion in the process. Two days later the patient
again, without any reason, laid bare the wound, which still presented the same
characters, except that the surface of the smooth clot showed, here and there,
some minute whitish specks, probably in consequence of the action of the watery
solution of carbolic acid with which it was washed two days previously. A
similar dressing was again employed, the use of carbolic lotion being again
necessarily involved. After two more days, that is to say a week after the
accident, the patient, though free from symptoms, having again removed the
dressings, the wound was again examined. It was free from pus or odour of
putrefaction, but its surface was mottled with red and yellow spots, and was
not quite level. The dressing was continued one day longer, when it was aban-
doned, as the patient could not be induced to leave it alone, water dressing
being used instead ; and on the following day the wound presented the characters
80 ON THE ANTISEPTIC SYSTEM
of a healing superficial granulating sore. Two days later, he was so unruly
that he was discharged for misconduct.
In the following case we have had the opportunity of seeing the effects of
this mode of dressing when left undisturbed.
Case of Compound Fracture of the Leg treated with Block-Tin and Antiseptic
Lac.—On the 3rd of October, 1868, a porter, twenty-five years old, was unloading
a wagon in a warehouse, when a box, weighing about four hundredweight,
slipped, and, striking him upon the left leg, knocked him down over an opening
in the floor, through which he would have fallen into the room below had not
the heavy box, pressing upon the limb, pinned him down and kept him sus-
pended. When rescued from this situation, he was taken to the infirmary,
where my house surgeon, Mr. Malloch, found the leg much distended with
extravasated blood, with a wound, three-eighths of an inch in length, on the
inner side, about midway between the knee and ankle, bleeding freely and
communicating with a transverse fracture of the tibia. A probe (smeared with
an oily solution of carbolic acid to prevent the introduction of septic particles)
could be introduced beneath the undermined fascia for about three inches in
every direction except downwards, and also passed, for the same extent, directly
outwards behind the tibia which was felt to be denuded of its periosteum.
Having injected into the wound, with a syringe, several ounces of a saturated
watery solution of the acid, and diffused it freely through the limb by pressure,
to mix it with the extravasated blood, Mr. Malloch placed a piece of thin block-
tin about an inch square over the orifice, and, after pressing out as much as
possible of the blood and watery solution, applied a piece of lac-plaster deprived
of its gutta-percha lining, overlapping the tin a couple of inches in every direction,
and over this a folded cloth moistened with a solution of carbolic acid in four
parts of olive oil. The limb was then put up in lateral pasteboard splints.
This treatment relieved the severe pain which he was suffering ; but it returned
in the course of the next few hours, during which very free haemorrhagic effusion
occurred. Next day the discharge became greatly diminished, and in the course
of the following day it ceased entirely. The pain also left him about twelve
hours after the accident and never returned. The after treatment consisted
for the first two days, in renewing the oily cloth once in the twenty-four hours ;
but from the third day onwards the cloth was left permanently upon the limb
and merely brushed over with a mixture of equal parts of carbolic acid and oil,
the inner splint being raised for the purpose without disturbing the limb, which
lay upon its outer side with the knee bent. After the sixth day, the antiseptic
oil was only applied once in forty-eight hours. On the third day, some wrinkling
ot the epidermis indicated subsidence of the swelling, which afterwards fell
OF TREATMENT IN SURGERY 81
rapidly till, by the eleventh day, the calf was almost of natural size, having
shrunk away considerably from the splint. His pulse never rose above 82,
which was its number the day after the accident, and his general health was
from that time forward quite unaffected.
Ten days after the receipt of the injury, it was noticed that the oily cloth,
which for a week past had indicated complete absence of discharge, exhibited
an appearance of additional staining, corresponding to two or three drops of
red serum which seemed to have been pent up beneath the lac-plaster by in-
spissation of the blood and serum round its margins, till some accidental cause,
such as the shrinking of the limb, cracked the dried exudation. Having been
led to disturb the dressing to some extent in investigating the source of this
discharge, I thought it best to remove it entirely, protecting the wound at the
moment of its exposure with a bit of antiseptic lint. The under surface of the
lac gave distinct indications of being impregnated with carbolic acid. The
wound presented a very interesting appearance. It had shrunk considerably ;
but its margins resembled those of a perfectly recent wound ; and its orifice
was occupied by a projecting dark clot, which to the naked eye scarcely differed
from a fresh coagulum. Hence there seemed reason still to hope for healing
without suppuration, if the original mode of dressing were repeated. Accord-
ingly, the tin smeared with carbolic acid was replaced, and overlapping it a fresh
portion of lac-plaster, rendered adhesive by touching it with carbolic acid after
removing the film of gutta-percha, except in a narrow space from the centre
to one side, where the gutta-percha was left, to provide for the escape of dis-
charge. A dry cloth and the splint completed the dressing. Two days later,
in order to maintain the lac-plaster in an antiseptic condition, two layers of
calico, moistened with a solution of carbolic acid in four parts of olive oil, were
substituted for the cloth; and afterwards, at intervals of from two to three
days, the surface of the calico was lightly brushed over with a mixture of equal
parts of the oil and acid. For six days, some yellowish serum, amounting at
first to one or two minims in twenty-four hours, but gradually diminishing,
exuded from below that part of the margin of the lac-plaster where the gutta-
percha film had been left, the amount being estimated by changing every day
a little bit of antiseptic lint placed at the point of exudation. But, after the
sixth day, the piece of lint was left unchanged, as the trifling discharge seemed
to have ceased entirely. When eleven days more had passed without any change,
I thought it well to ascertain again the state of the wound ; and on the 30th of
October, seventeen days after the second application of the deep dressing, and
two days short of four weeks after the accident, I pulled off the lac-plaster with
the tin adhering to it. The plaster was still sticking to the skin, and drew
LISTER IL G
82 ON THE ANTISEPINCISY SIEM
away the hairs along with it, except where the gutta-percha film remained.
At this part, along the course of the track of exudation, the skin had an orange
stain, from serum mixed with altered haematin, and was moist, except near
the edge of the plaster. Beneath the tin, also, there was the same kind of
orange moisture. The wound appeared at first sight unhealed, having an orange-
red aspect ; but, on wiping it with a piece of lint, a perfect cicatrix was disclosed,
which had been covered with the remains of the little portion of clot seen pro-
jecting from the orifice on the former occasion of exposing it. A piece of dry
lint was placed upon the scar; and the splints were readjusted, the fragments
being in good position. The case was now reduced to one of simple fracture.
This case presents several features of great interest. In the first place,
the appearances disclosed on the removal of the dressings on the tenth day
after the accident afford as good an illustration as could be desired of the fact
that the surface of a wound is not induced to suppurate, or indeed to undergo
any appreciable change by the contact of a foreign body, destitute of chemically
stimulating properties. The carbolic acid with which the surface of the tin
was washed, like that injected into the wound, was absorbed into the circulation
before it had time to bring about those changes in the part which are the essential
preliminary to suppuration. The tissues of a recent wound are incapable of
forming pus, however much they may be stimulated, whether by nervous (1.e.
inflammatory) excitement, or by chemical irritants, such as the products of
putrefaction or pungent antiseptics. It is only when they have been gradually
changed under the influence of prolonged abnormal stimulation into that rudi-
mentary form of tissue which, when we see it on the surface of a sore, we term
granulations, that they are liable to produce, when still further stimulated,
the still more rudimentary pus corpuscle. It is upon this that the possibility
of obtaining primary union on the antiseptic system depends. The antiseptic
applied to the wound in the first instance is a powerful stimulant, but it is
absorbed before it has time to bring about granulation in the tissues.
In the second place, it is very satisfactory to see, although theoretically
it could hardly have been doubted, that, when a wound has been effectually
protected from stimulation and consequent granulation, it may, even at a late
period after its infliction, be again subjected to the temporary stimulus of an
antiseptic application without being made to suppurate; for a knowledge of
this fact will enable us to examine the wound when we think there is a fair
prospect of healing being complete, confident that, should the reverse prove
to be the case, we can again employ the original mode of dressing without inter-
fering with the process of healing by scabbing.
Thirdly, I may remark that cicatrization without suppuration beneath
OF TREATMENT IN SURGERY 83
a piece of tin is a novel mode of healing by scabbing. But the ordinary scab
is in so far analogous to the metallic plate, that the exudations of which it is
composed having dried before they had time to putrefy, the crust is, like the
metal, a neutral or unstimulating solid. Further, there is putrescible moisture
beneath the scab as beneath the tin; but the mode in which the putrefactive
organisms are excluded is essentially different. The scab keeps them out
mechanically, by adhering firmly to the surface of the integument ; the metallic
plate opposes no mechanical barrier to their entrance, but is guarded by a germ
poison in the surrounding lac which no less imperatively forbids their access.
Altogether the case must be regarded as affording great encouragement
for giving a further trial to this method, which seems to bring the treatment of
compound fracture to something nearly approaching perfection. The lac, being
impermeable to discharge, combines the properties of an external antiseptic
guard with those of a permanent crust; and, as fresh carbolic acid can be
supplied to it as often as may be desired without disturbing its position, the
trouble and risk that attended the changing of the putty are entirely got rid of.
At the same time the tin protects the raw surface from the acid with absolute
certainty, while the tin and the lac constitute together so thin a layer as not
to alter the contour of the limb, or interfere with the shape of splints such as
would be used for simple fracture ; a considerable advantage as compared with
the mass constituted by a thick crust, covered with substantial putty. When
the wound is large, I would advise the use of two layers of the lac-plaster for
the sake of additional strength, the outer one overlapping the inner by an inch
or two; and the outer, like the inner, rendered adhesive, as above described,
so that the two may become incorporated into one mass. Also, I would recom-
mend that, as was done in the second dressing of the last case, the film of gutta-
percha should be left upon a track leading from the tin to what is to be the most
dependent part of the edge of the plaster to afford free egress for sero-sanguineous
discharge.
For treating the interior of the wound in compound fracture, I employed,
till comparatively lately, the undiluted acid, and, as this afforded excellent
results, I did not venture to change the practice without having some more
substantial basis than hope to found upon. But rather more than a year ago,
having observed that the injection of a saturated watery solution (one part
of acid to twenty parts of water) among the fibrous tissues in a fetid suppurat-
ing wound of the palm, completely arrested the existing putrefaction, I con-
cluded, that if the acid so diluted sufficed to destroy the abounding putrefactive
organisms which must have been present among the textures in that case, it
must surely be trustworthy for compound fracture. We have accordingly
G2
84 ON THE ANTISEPTIC SYSTEM
employed the saturated watery solution in all the numerous cases of compound
fracture that have since come under my care, and in no instance has it failed.
If it answers equally well, it is obviously superior to the strong acid, since it
does not produce the slightest sloughing from caustic action, and, being a less
powerful irritant, causes a less copious serous effusion. Besides, it may be
injected and diffused among the tissues which are the seat of extravasation
with a freedom which could not be used with the acid of full strength, and it is
to this circumstance that I am disposed to attribute the fact that we have
obtained success at a period after the infliction of the injury which I should
formerly have thought quite hopeless, in one case, for example, as late as thirty-
six hours after the accident. Lastly, we avoid a disagreeable symptom which
we used to observe occasionally after applying the undiluted acid freely to large
wounds, viz. obstinate vomiting for about twenty-four hours, occasioned, no
doubt, by imbibition of a poisonous dose into the circulation.’
Catgut, manufactured from the small intestine of the sheep,” may be had
at a very low price, from the thickness of a horsehair upwards. In the dry state,
it is somewhat objectionable from its rigidity, and also from a tendency of the
first half of the knot to slip before the second half is secured. Water renders
it perfectly supple, and as little liable to slip as waxed silk. But if a watery
solution of carbolic acid be used for the purpose of making it antiseptic, the
protracted immersion requisite to ensure completeness of the effect makes the
finer kinds too weak, and the stouter too clumsy so that it will not enter the
eye of an ordinary aneurysm-needle. The method which I have found to answer
best is to keep the catgut steeping in a solution of carbolic acid in five parts of
olive oil, with a very small quantity of water diffused through it. A larger
proportion of the acid would impair the tenacity of the thread. If a mere oily
solution be employed, the gut remains rigid, the oil not entering at all into its
substance. But a very small quantity of water, such as the acid enables the oil
to dissolve, renders the gut supple, without making it materially weaker or
thicker. And, curiously enough, the presence of this small amount of water
in the oily solution gradually brings about a change in the gut, indicated by
a deep brown colour, after which it may be placed in a watery solution for a long
time, without swelling as a portion prepared in a simple oily solution does.
This is a great convenience. For an oily solution is unpleasant to work with
* A report of the case of ligature of the external iliac artery mentioned in the footnote to p. 65,
together with an account of the conditions found post mortem, as also a report of the ligature of the
carotid artery in the calf are omitted in this place since they are given more conveniently at pp. 88-98
of this volume.
* I need hardly remark that catgut is of a totally different nature from the so-called silkworm gut,
which is in reality unspun silk. [The reader may consult also pp. 107-8.]
OF TREATMENT IN SURGERY 85
during an operation; and exposure to the air soon renders gut suppled with
water rigid from drying. But, when it has been treated in the way above recom-
mended, it may be transferred to a watery solution at the commencement of an
operation, and so kept supple without having its strength or thickness altered.
For tying an arterial trunk in its continuity, catgut as thick when dry as
ordinary purse-silk will be found best ; but for ordinary wounds, where, if one
ligature happen to break, another can be easily applied, much finer kinds may
be employed, and are convenient from their smaller bulk. For everyday use,
a small oil-tight capsule may be carried in the pocket-case ; and this case can
be replenished from a larger stock as may be necessary. I have had a small
silver bottle with well-fitting screwed top adapted to my caustic case ; and this
contains two little rods of wood with gut of two sizes wound upon them, together
with a few drops of the antiseptic oil: and now that torsion has almost entirely
superseded the ligature in ordinary wounds, this small supply will probably
last me for months.
OBSERVATIONS ON LIGATURE OF ARTERIES
ON THETANTISEPTIC SYSTEM
[Lancet, 1869, vol. i, p. 451. Corrected February 1870.]
VARIOUS attempts have been made, both in the early part of the century
and more recently, to improve the ligature, or to supersede it by other methods.
Nevertheless, for obstructing the calibre of an arterial trunk in its continuity,
no means hitherto devised have proved superior to a small silk thread tied in
a secure knot, with the ends left projecting from the wound. Yet, as is implied
by the numerous efforts at improvement, the ligature in this form is far from
perfect. The internal and middle coats are ruptured by the constricting noose,
while a portion of the tough external coat is pinched together and deprived
of its vitality. The dead tissue, becoming contaminated by the putrefaction
which occurs in the interstices of the silk fibres, acts, together with the septic
ligature, as a cause of irritation to the neighbouring parts of the arterial wall,
which consequently degenerate into an imperfect structure, inadequate to
withstand the powerful cardiac impulse ; and even before the slough separates
by suppuration, the blood breaks through the feeble barrier, unless it be fortified
by a firm plug of internal coagulum. Hence, if a considerable branch takes
origin close to the part tied, the formation of a clot being prevented by the
current of blood, secondary haemorrhage is the inevitable consequence ; and
thus the ligature is inapplicable in situations otherwise eligible for it, such as
the femoral artery near Poupart’s ligament, the origins and endings of the
iliacs, and the innominate.
Even when the thread is distant from any considerable branch, the terrible
risk of haemorrhage cannot be said to be altogether absent. The degenerate
structure of the vessel near the ligature, unlike the arterial wall in its normal
condition, is prone to ulceration, and the organizing coagulum is similarly
circumstanced ; so that an unhealthy state of the wound may open up the
calibre of an artery tied in the most favourable situation.
* It has been long since noticed that haemorrhage occurs more frequently from the distal than
from the cardiac end of the vessel. This seems at first sight contrary to what might be expected, since
the cardiac end is subjected to much greater strain. The explanation is, I believe, afforded by some
facts which I had occasion some years ago to point out. (See the Croonian, Lecture ‘On the
Coagulation of the Blood,’ printed in vol. i, p. 109.) It was then shown that a perfectly undis-
turbed coagulum resembles healthy living tissue in failing to induce coagulation in blood near it ;
but that, on the other hand, while a clot is, from its softness, peculiarly liable to laceration and other
disturbance, a disturbed coagulum acts like injured tissue in impressing upon neighbouring blood a
coagulating tendency. Hence, when a ligature has been tied round an artery, although a minute clot
OBSERVATIONS ON LIGATURE OF ARTERIES 87
Again, when the parts about the vessel communicate with loose cellular
interspaces in important regions, as is the case with the iliac arteries or the
subclavian, diffuse suppuration is frequently a cause of death. Finally, the
cure is always rendered tedious by the time required for the separation of the
ligature ; while the presence of an external wound during the period thus pro-
tracted involves a risk, by no means inconsiderable in some localities, of hospital
gangrene or erysipelas.
The Antiseptic System, however, places this branch of surgery, like most
others, in a new light. One point which it has brought out in striking relief is,
that a portion of dead tissue is not necessarily thrown off by suppuration, but,
unless altered by putrefaction or artificially imbued with stimulating salts,
serves as pabulum for the surrounding living parts, which remove it by a sure
process of absorption. Hence, the death of a portion of the external coat in-
cluded in the ligature does not of itself render it a cause of suppuration. And
I conceived that if a silk thread, steeped in some liquid capable of destroying
the septic organisms in its interstices, were tied round an artery, and left with
short-cut ends in a wound dressed antiseptically,t the foreign body, soon losing,
by diffusion into the circulation, the stimulating salt with which it was saturated
at the outset, and being in its own substance as unstimulating chemically as
a pellet of lead from a fowling-piece, would either remain, like the latter, per-
manently encapsuled, or itself experience absorption together with the dead
tissue in its grasp. In either case, being destitute of irritating properties, it
should leave the primitive strength of the arterial coats unimpaired ; when the
objection to tying near a large branch would cease to exist. The wound mean-
while would, under proper management, close rapidly, without any deep-seated
suppuration, and would be efficiently protected against the evil influences of
impure atmosphere. In short, the ligature of an arterial trunk in its continuity
would be brought to a state of perfection.
I have subjected these theoretical views to the test of experience ; and
though the results have not turned out in all respects exactly as I had anticipated,
yet those finally arrived at appearing satisfactory, I now present to the profession
an account of all that I have done in the subject.’
necessarily forms upon the injured internal and middle coats, it would undergo no increase if the blood
in the vessel were absolutely quiescent. But the pulsations of the artery operate as a disturbing cause
to the clot already formed, which consequently increases in proportion to the degree of the disturbance ;
and as this is much greater at the cardiac side, the clot grows more quickly there, and forms a more
secure barrier against the pressure of the blood.
1 In using the expression ‘ dressed antiseptically’, I do not mean merely ‘ dressed with an antiseptic’,
but ‘ dressed so as to ensure absence of putrefaction ’.
* A brief account given in the original of the case of ligature of the carotid artery in the horse with
silk thread on the antiseptic system more fully reported at p. 64 of this volume, has been omitted in this
place.
88 OBSERVATIONS ON LIGATURE OF ARTERIES
Case of Ligature of the External Ilac Artery on the Antiseptic System..—On
the zgoth of January, 1868, I was requested by Dr. Fergus to see a lady
fifty-one years of age, who was suffering from an inguinal aneurysm which had
existed for four years, but had of late been markedly on the increase, causing
agonizing pain, which had confined her to bed for the last four weeks, and had
considerably reduced her strength. The aneurysm was of the size of a large
orange, affecting the uppermost part of the left femoral artery, and extending
a little above Poupart’s hgament. Any delay appearing undesirable, I tied the
external iliac on the following day, in presence of Dr. Fergus, and assisted by
Messrs. Hector Cameron, Appleton, and James Coats. There was nothing
peculiar in the operation, except that the incision was made a little further
outward than usual, in order to avoid the upper part of the aneurysm. The
only bleeding vessel that required attention was twisted. The ligature employed
had been previously steeped for two hours in strong fluid carbolic acid, pre-
pared by adding a small proportion of water to the crystals. The tightly
twisted thread requires a considerable period of immersion to ensure thorough
soaking with the liquid ; and the acid does not impair the tenacity of the fibre.
At the time of the operation, the superfluous acid was removed by transferring
the silk to a solution of carbolic acid in thirty parts of water; and the same
lotion was used for the sponges, and also for washing the aneurysm-needle before
it was passed round the vessel. The artery having been tied, and the ends
of the ligature cut short, the wound was freely treated with the watery solution,
some of which was poured in, to make sure that it penetrated to every part.
The edges of the skin were then brought together with silver sutures, except
in the middle, where I introduced a pledget of lint steeped in a solution of the
acid in five parts of olive-oil ; passing it deeply, but leaving one end projecting
externally, to serve as a drain for blood and serum. I then applied an external
antiseptic dressing, the details of which I need not now describe. The pledget
of lint was cautiously withdrawn on the following day, under cover of a pretty
large piece of lint imbued with the antiseptic oil; and the external dressing
was reapplied, and afterwards changed at intervals proportioned to the diminu-
tion of the serous discharge, which, at the end of a fortnight, was estimated at
about three minims in three days. At this time, some portions of lint, which
had been left till then undisturbed, were removed, when the wound was found
quite free from pus, being perfectly cicatrized where the sutures were intro-
duced ; while the central part, where the pledget was placed after the operation,
* The report of this case down to the account of the condition of the patient on July 25, 1868, has
been inserted here from the address on the Antiseptic System of Surgery (p. 51), and has been omitted
from that address (p. 65).
ON THE ANTISEPTIC SYSTEM 89
presented the appearance of a superficial sore, but not a granulating one: for
the deep surface of the dressing, being devoid of stimulating properties, had
failed to induce granulation in the tissues on which it lay. Meanwhile the
patient had been relieved from the pain which she previously suffered, without
experiencing febrile disturbance or any material inconvenience from the opera-
tion, except uneasiness in the wound the first two days, during retching occa-
sioned by the chloroform. The tongue had been natural throughout: the
pulse had only on one day been as high as go, 72 to 84 being the usual rates ;
and her appetite, which had been absent during the four weeks of agony that
preceded the operation, returned two days after it, as soon as the derangement
of the stomach from chloroform subsided. On the fourteenth day, as I was
arranging her pillows, she sat upright without inconvenience. Four weeks after
the operation, the wound being completely cicatrized, she was allowed to move
about in her room; and, just six weeks from the date of the ligature of the artery,
she descended three long flights of stairs, walked for some time in the streets, and
reascended the steps to her lodgings ; and, though fatigued by the effort, she felt
next day all the better for it. On the 31st of March, she called to see me, much im-
proved in strength, though with still some tendency to swelling of the legs, especially
the left, when in the erect posture. The aneurysmal swelling felt merely like a
slight glandular thickening. On the 25thof July, 1868, I again visited her. She
had derived much benefit from a stay at the seaside, and the tendency to oedema
of the extremities was greatly diminished. There was still absence of pulsation
in the external iliac artery, and the cicatrix remained quite sound twenty-five
weeks after the operation.
She continued for about ten months in fair health and strength; but,
in the latter part of November, she became affected with a peculiar spasmodic
disorder of the respiration, and on the morning of the 30th of the month, while
sitting up in bed, she suddenly exclaimed that something had given way within
her, and that she was dying, and then immediately expired. Next day I made
a post mortem examination, when the idea which she had expressed proved
correct—an aneurysm of the descending part of the arch of the aorta having
given way, and discharged an enormous quantity of blood into the mediastinal
and subpleural cellular tissue. The parts concerned in the operation having
been removed and dissected, the following appearances were disclosed. The
aneurysm was not entirely obliterated ; but remained about the size of a cherry
or large filbert, of somewhat fusiform shape. The upper two-thirds were solid,
being occupied by firm coagulum incorporated with the sac. The lower third,
situated just at the bifurcation of the common femoral, had been kept free from
coagulation by the regurgitant stream of blood from the profunda into the
go OBSERVATIONS ON LIGATURE OF ARTERIES
superficial trunk. This part of the sac appeared constituted by the wall of
the vessel, very slightly distended. The external iliac artery was considerably
shrunk throughout, and tapered from each end to near the middle, where it was
only about a twentieth of an inch in diameter. In the greater part of its length
the structure of the dwindled vessel could be distinctly recognised, with ad-
herent coagula in the interior, decolourized and otherwise altered. But at the
narrowest part the artery was reduced to mere fibrous tissue, constituting
a dense white band five-eighths of an inch long, from the middle of which was
seen projecting at one side a round, buff-coloured appendage about a line in
diameter, somewhat obscured by a trifling amount of inflammatory condensation
of texture in the immediate vicinity. On scratching this little body with the
point of a knife, I found it to be a very thin-walled capsule, containing the knot
of the ligature, with two tapering ends, which were shorter than the thread
was cut at the operation, while the noose had vanished altogether. The surface
of the knot also showed clear indications of having been subjected to an eroding
agency, similar, no doubt, to that exerted by granulations upon dead bone
absorbed by them.t Besides the remnant of the ligature, the tiny capsule
contained a minute quantity of yellowish, semi-fluid material, looking to the
naked eye like very thick pus. Under the microscope, however, pus-corpuscles
were seen to form but a small proportion of its constituents, which were prin-
cipally rounded corpuscles of smaller size, and fibro-plastic corpuscles, together
with some imperfect fibres and granular material. In addition to these elements
were some which at first puzzled me; but which turned out to be fragments
of silk fibre, of various lengths, and of jagged, tapering, or otherwise irregular
forms, and many of them greatly reduced in thickness, contrasting strongly
with the uniform bands of a fresh piece of silk from the same reel that had
furnished the ligature (Fig. I).
Mingled with the puriform fluid were also some delicate filaments of silk,
visible without the microscope ; and these seemed to retain their natural elas-
ticity. Nor was there anything about the more minute pieces into which the
fibres had been so strangely chopped up, to indicate that they were undergoing
a process of solution or softening by the fluid that soaked the thread. They
had rather the appearance of having been superficially nibbled, so to speak ;
confirming the impression conveyed by the naked-eye characters of the knot,
that the silk had been eroded by the absorbing action of the surrounding parts.
Indeed, considering the organic origin of silk, the remarkable thing seems to be,
not that it should be absorbed by the living tissues, but that it should resist
their influence so long.
* See Lancet, March 23, 1867 (p. 16 of this volume).
ON THE ANTISEPTIC SYSTEM gI
Why it was that the parts in immediate contact with the silk should have
assumed so imperfect a structure is a difficult question, but one of great interest :
because, although that structure could not be called pus, it was certainly a very
near approach to it ; and it is impossible to say that we had not here an incipient
abscess. There can be no doubt that the presence of the thread was in some
way or other the cause, and I think we can hardly be wrong in assuming that,
Fic. 1.—Constituents of the incipient abscess(?) around the remains
of the silk ligature. Magnified 500 diameters. From a camera-lucida
sketch. A, a pus corpuscle; B, rounded corpuscles of smaller size ;
C, fibro-plastic corpuscle with endogenous cell-development; D, ordinary
fibro-plastic corpuscles; EF, irregular fragments of silk fibre partially
absorbed ; F, a piece of fresh silk fibre introduced for comparison.
in order to give rise to such degeneration of tissue, it must have operated as
a persistent, if trifling, source of abnormal stimulation. Now, as putrefaction
is here out of the question, and as the substance of silk is not chemically stimu-
lating, we seem shut up to the conclusion that the thread must have occasioned
disturbance of a mechanical nature. Further, the effect in question seems to
be essentially connected with the disintegration of the silk. Tor in the horse's
carotid! the silk ligature, having remained unaltered during the six weeks that
' See p. 65 of this volume.
92 OBSERVATIONS ON LIGATURE OF ARTERIES
had passed after the operation, was found surrounded on all sides by compact
tissue ; and in the present case, so long a period as ten months having elapsed
before the puriform condition was observed in an apparently incipient stage,
it is probable that the thread had lain for a long time inert, producing irritation
only when partially absorbed. If, then, we inquire how the disintegrating silk
could prove a source of mechanical irritation, it seems not improbable that it
may have been from the sharp and jagged fragments of the fibre perpetually
fretting the elements of the living tissue around them. This view, if correct,
would explain the curious fact observed by Lawrence and others, that when
fine silk ligatures had been left with short-cut ends in a stump, though the wound
might heal without their separation in the first instance, they were liable
to make their appearance subsequently, sometimes at so late a period
as seems to exclude the idea of putrefaction having occurred from organisms
introduced into the threads. Indeed, such ligatures occasionally showed them-
selves encapsuled in little nodules in the cicatrix, without suppuration occurring
at all. In other words, the apparently soft silk, instead of remaining, like
a smooth leaden pellet, permanently embedded in the place where it was first
introduced, made its way to the surface with or without suppuration, like a
sharp spiculum of rigid glass ; the silk being in its minute structure comparable
to the pellet when in the primitive condition of smooth continuous fibres, and
to glass spicula when in the form of jagged fragments as the result of partial
absorption.
But whatever may be thought of this explanation, it is clear that if there
is any chance of silk, though used antiseptically, giving rise, even in exceptional
cases, to abscess in the vicinity of an artery tied with it, this is a serious objection
to its employment ; and as the near approach to suppuration in the present
instance was undoubtedly occasioned by the persistent presence of the thread,
the case, while interesting as affording evidence that silk is susceptible of absorp-
tion, suggests the expediency of substituting for that material some other sub-
stance which can be more readily taken up by the tissues.
The use of ‘ animal ligatures’, of catgut, leather, or tendon, was long since
tried and abandoned as unsatisfactory ;? but after the experience which the
antiseptic system has afforded of the disappearance, without suppuration, of
large dead pieces of skin and other textures, there could be little doubt that
threads of animal tissue, if applied antiseptically, would be similarly disposed of.
And even if chemical processes should have been used in preparing such
threads, it did not seem likely that this would interfere with their absorption ;
* See Cooper’s Surgical Dictionary, 7th edition, article Aneurysm.
* Op. cit., articles Aneurysm and Ligature.
ON THE ANTISEPTIC SYSTEM 93
for I knew that the free action of carbolic acid on blood and sloughs had no such
deterring influence, and I have long been satisfied that the injection of a strong
solution of perchloride of iron or tannic acid for the cure of naevi produces
subcutaneous sloughs, which are imbued with the ingredients injected, and yet
disappear, as a rule, without the formation of pus.
In order to put the antiseptic animal ligature fairly to the test, I made the
following experiment :—
Ligature of the Carotid Artery in the Calf on the Antiseptic System, with
Threads composed of Animal Tissue.—On the 31st of December, 1868, I tied
the right carotid artery about the middle of the neck in a healthy calf a few
days old, the animal being under chloroform. Ligatures of two different kinds
were employed, at an interval of about an inch and a half, the sheath of the
vessel being left undisturbed in the intervening part. The cardiac ligature
was of home manufacture, composed of three strips of peritoneum from the small
intestine of an ox, firmly twisted together into a three-fold cord. The distal
thread was of fine catgut, called ‘ minikin gut’ by the London makers. Both
had been soaked for four hours in a saturated watery solution of carbolic acid,
which swelled and softened them, so that the thread of my own making was
too large to enter the eye of the aneurysm-needle except near the ends, where
it was thinner than elsewhere. This substantial ligature bore the strain of
tying well, but the fine catgut broke as I tightened the noose. I did not, how-
ever, remove it, but having a second piece at my disposal, passed it round at the
the same place, and with gentle traction completed the knot. There were thus
two ligatures of the fine gut at the distal site. All were cut short, except one
end of the catgut, which I purposely left about three-quarters of an inch long,
to give a better opportunity of ascertaining what would become of the foreign
material. The antiseptic arrangements were as follows: Before the operation
the hair of the part was cut short, and a solution of carbolic acid in four parts
of linseed oil (preferred for its cheapness) was rubbed well into the skin, to destroy
any putrefactive organisms lying amongst the roots of the hairs; for any so
situated might escape the action of the external antiseptic dressing, and com-
municate putrefaction to the discharges, and thence to the interior of the wound.
The sponges used in the operation were wrung out of a watery solution of the
acid (x to 40), and all the instruments introduced into the wound, together
with the fingers of my left hand and the copper wire used for sutures, were
treated with the same lotion, some of which was poured into the wound after
the introduction of the last stitch, at one of the intervals left for the escape
of discharge, to make sure against the chance of any fresh ,blood which had
oozed out during the process of stitching having regurgitated and taken living
94 OBSERVATIONS ‘ON LIGATURE OF ARTERIES
germs in with it. The external dressing was a towel saturated with the oily
solution, folded as broad as the length of the neck, round which it was wrapped
so as to extend freely beyond the wound in all directions, prevented from slipping
backward and forward by being stitched to a halter round the head, and to
a girth behind the forelegs, while a bandage rolled round it kept it applied accu-
rately to the surface. A sheet of gutta-percha tissue, to prevent contamination
of the antiseptic towel from without, and another roller, completed the dressing ;
and a ‘cradle’ was placed upon the neck to check lateral movements which
might disturb it. I have described these particulars because I am more and
more convinced of the necessity for scrupulous attention to details such as
the germ theory dictates, in order to attain anything like uniformity of
successful results.
A few ounces of the oily solution were poured daily over the towel for the
first week, after which the dressings were left untouched for three days, and
then entirely removed. The wound was found quite dry and free from tender-
ness, and the cloth showed only a superficial bloody stain. The stitches being
taken out, a drop of pus escaped from the track of the suture next the head ;
but this was the only appearance of suppuration in the case from first to last,
and on the separation of the scab, a few days later, a sound cicatrix was disclosed.
A month (thirty days) after the operation the animal, which had continued in
perfect health, was killed, and the soft parts of the neck below the spine were
removed for examination. On dissection I was struck with the entire absence
of inflammatory thickening in the vicinity of the vessel, the cellular tissue
being of perfectly normal softness and laxity. On exposing the artery itself,
however, I was at first much disappointed to see the ligatures still there to all
appearance as large as ever. But had I borne in mind what I had observed
in some of my earlier cases of compound fracture treated antiseptically, I should
have been prepared to find these threads present in appearance, though absent
in reality. It may be well for me to quote from the account I have before
given of one of these cases.1 It was a compound fracture of the leg, produced
by direct violence, with a wound of considerable size, and a great deal of extra-
vasation of blood into the limb. In accordance with the practice which I then
followed, a piece of lint soaked with undiluted carbolic acid had been placed
over the wound, and had formed with the blood a firm crust. ‘ Nearly three
weeks after the accident I was detaching a portion of the adherent crust from
the surface of the vascular structure into which the extravasated blood beneath
had been converted by the process of organization, when I exposed a little
spherical cavity about as big as a pea, containing brown serum, forming a sort
* See Lancet for March 16, 1867, p. 328 (p. 8 of this volume).
ON Thr “ANTISEPTIC SYSTEM 95
of pocket in the living tissues, which, when scraped with the edge of a knife,
bled even at the very margin of the cavity. This appearance showed that the
deeper portions of the crust itself had been converted into living tissue. For
cavities formed during the process of aggregation, like those with clear liquid
contents in a Gruyére cheese, occur in the grumous mass which results from
the action of carbolic acid upon blood; and that which I had exposed had
evidently been one of these, though its walls were now alive and vascular.’
Thus the dead, but nutritious mass, had served as a mould for the formation of
new tissue, the growing elements of which had replaced the materials absorbed,
so as to constitute a living solid of the same form.
Hence it might have been anticipated that the ligatures of peritoneum
and catgut placed on the calf’s carotid would, after the expiration of a month,
Fic. 2.—The vessel seen in longitudinal section, magnified three
diameters. From acamera-lucida sketch. A, the artery to the cardiac
side of the ligature, kept free from clot by the stream of blood through
the branch B. C, the coagulum filling the artery to the distal side of the
ligature, F, F. D, the middle and internal coats, somewhat thickened
and blended together within the grasp of the ligature. £, the external
coat continuous in structure with the organized ligature.
be found transformed into bands of living tissue. Such was, in truth, the case,
as was apparent on closer examination. They had, indeed, a deceptive resem-
blance to their former condition, from the persistence in their substance of the
impurities of the original materials, the dark adventitious particles being of
mineral nature incapable of absorption, so that they had remained as a sort
of tattooing of the new structure. Nevertheless, a marked alteration in colour
had taken place, especially in the distal ligature, where the dirty grey of the
softened catgut had changed to a dirty pink tint. The two pieces of catgut
which had been tied round the vessel at that part had become, as it were, fused
together into a single fleshy band, inseparably blended with the external coat
of the artery. The knots were nowhere discoverable, and the only indication
of the end which had been left long at the time of the operation was the presence
of a black speck here and there upon a delicate thread of cellular tissue in con-
nexion with the vessel. The cardiac ligature was in like manner continuous
96 OBSERVATIONS ON LIGATURE OF ARTERIES
in structure with the arterial wall. The short ends had disappeared ; but the
massive knot was represented by a soft smooth lump, which appeared at first
entirely homogeneous, except that it was speckled with dark particles, as before
referred to. On section, however, I discovered in the interior of the mass,
and lying close to the wall of the artery, a small residual portion of the original
knot, of comparatively firm consistence, and with the three-fold twisted character
of the cord plainly visible. It was quite distinct from the living tissue that
surrounded it, so that it could be readily picked out from its bed with a pair
of needles. A slender and irregular remnant of the noose was also found lying
in a sort of tubular cavity, extending about half round the vessel.
Thus the process of organization had not yet quite invaded the entire
thickness of the foreign solid, and it was a happy circumstance that the thread
had been so constructed that the distinction between the old structure and the
new could be plainly recognised.
Ample as was the evidence afforded to the naked eye of the organization
of these ligatures, it was satisfactory to find it confirmed in the clearest manner
by the microscope. A bit of the residue of the peritoneal thread, having been
teased out with needles in a drop of water, presented, like a fresh piece of peri-
toneum, the wavy bundles of parallel fibres characteristic of perfectly developed
fibrous tissue. Adhering to the surface of the remnant of the ligature was some
soft opaque material, readily washed off with water, consisting of corpuscles of
different forms, most of them caudate or fibro-plastic, but some spherical, though
not resembling those of pus; and here and there fragments of the original
peritoneal tissue, affected more or less with interstitial cell-development. At
a short distance from the remains of the old thread, the fleshy material which
had been formed at its expense proved to be a most beautiful example of fibro-
plastic structure, the coarse fibres which mainly constituted it being composed
of very large elongated cells, often containing several nuclei, and presenting in
their course branchings and thickenings of various forms, as represented in the
sketch (Fig. 3). Here and there were some fibres more perfectly formed, and
also cells of a more rudimentary character. Again, the band which had resulted
from the organization of the two fine threads of catgut, which, from the smallness
of their bulk, had no doubt vanished early, having had longer time to perfect
its structure, was a comparatively well-developed form of fibrous tissue, con-
sisting of coarse fibres rather than of elongated cells, being thus intermediate
between the merely fibro-plastic material of more recent growth and the com-
pleted texture of the original thread. For it is to be remarked that a piece of
catgut exhibits under the microscope abundance of perfect fibrous tissue. A
more favourable period for the investigation, with a view to establishing the
ON THE ANTISEPTIC SYSTEM 97
nature of the change which ligatures of animal tissue experience under antiseptic
management, could hardly have been selected.
Between the parts tied the calibre of the artery was occupied by adherent
coagulum, which was for the most part decolourized, and exhibited under the
microscope fibro-plastic cells of irregular forms. A similar clot was present
between the distal ligature and a small branch that arose about a quarter of
an inch beyond it. But between the proximal ligature and the heart the forma-
Fic. 3.—Some of the elements of the fibro-plastic structure of the
organized peritoneal ligature at the knot F. From a camera-lucida sketch.
Magnified 500 diameters.
tion of a coagulum had been entirely prevented by a large vessel taking origin
immediately above the part tied, which had thus borne for a month the full
brunt of the cardiac impulse. Yet the vessel, so far from showing any sign of
giving way, as it would inevitably have done had it been tied in such a situation
without antiseptic precautions, appeared to have derived additional strength
from the operation. The encircling ring of new tissue incorporated with the
arterial wall must have had a corroborative effect ; and within its grasp the
inner coats, which seemed to have been but imperfectly ruptured by the soft
and substantial ligature, were considerably thickened, and had coalesced so
LISTER II H
98 OBSERVATIONS, ONFTIGATURE OF ARTERIES
as to form a strong cul-de-sac, the irregularities of which had been smoothed
over by a little fibrinous deposit, which had assumed the characters of a firm
fibrous tissue, and presented a free surface undistinguishable from that of the
lining membrane of the artery (Fig. 2).
At the situation of the distal ligature the structure of the vessel seemed
entirely unaffected. The middle coat was seen in longitudinal section as a pink
streak between two white lines, representing the external and internal tunics,
neither thicker nor thinner than in neighbouring parts. The catgut threads
had been tied too gently to produce rupture of the internal and middle layers,
and their presence and the constriction which they occasioned, whatever may
have been their effect in the first instance, had left no permanent marks of
disturbance ; while the fleshy band that had replaced them, though in time it
would doubtless have dwindled down to an insignificant filament, was at least
a temporary addition to the strength of the artery.
These appearances at the distal ligature are calculated to revive under
a new aspect the old question whether it would not be better always to avoid
rupture of the internal and middle coats, which could easily be done by using
a pretty thick piece of catgut softened by steeping it in a watery solution of
carbolic acid. In this way the wall of the vessel would be left from first to last
entirely intact. This, however, is probably a matter of indifference. Indeed,
judging from the condition of the artery at the cardiac ligature, the injury done
to the vessel at the outset by tight tying seems to lead to changes which increase
its power of resistance, which was certainly severely tested in the present instance.
It appears, then, that by applying a ligature of animal tissue antiseptically
upon an artery, whether tightly or gently, we virtually surround it with a ring
of living tissue, and strengthen the vessel where we obstruct it. The surgeon,
therefore, may now tie an arterial trunk in its continuity close to a large branch,
secure alike against secondary haemorrhage and deep-seated suppuration—
provided always that he has so studied the principles of the antiseptic system,
and so carefully considered the details of the mode of dressing best adapted to
the particular case in hand, that he can feel certain of avoiding putrefaction
in the wound. For my own part, I should now, without hesitation, undertake
ligature of the innominate, believing that it would prove a very safe procedure.
Catgut, manufactured from the small intestine of the sheep,! may be had
at a low price, from the thickness of a horsehair upwards. As sold in the shops,
however, it is quite unfit for the purposes of the surgeon. For, when moistened
with water or with the animal fluids, it becomes not only very soft and weak,
* I need hardly remark that catgut is of {a totally different nature from so-called silkworm’s gut,
which is in reality unspun silk. (See also p. 84 of this volume.)
ON THE ANTISEPTIC SYSTEM 99
but as slippery as a piece of recent intestine, so that a knot tied upon it yields
to the slightest traction. But it is a happy circumstance that a simple process
of preparation deprives it of these objectionable qualities. For this purpose,
no method which I have yet tried answers better than that which I happened
to use first of all for rendering the gut antiseptic—viz. suspending it in a mixture
of five parts of some fixed oil (e.g. olive or linseed) with one part of carbolic
acid liquefied by adding five per cent. of water to the crystals. Part of the
water associated with the acid is disengaged by the oil, producing a very fine
emulsion, which effects a remarkable physical change in the animal tissue.
At first the gut is rendered swollen, soft, and opaque, though not to so great
an extent as if placed in simple water; but in the course of a few days the
opposite change begins to show itself, and the thread becomes gradually firmer
and more transparent, till, after the lapse of a few weeks, it is quite free from
opacity, and very strong, though supple. If drawn through the fingers, it is
no longer slippery, but has a crisp feel like a thread of india-rubber, and a knot
tied upon it holds more securely than one on waxed silk. Water, whether cold
or at a temperature of 100° Fahr., has now little effect upon the thread, and
even putrid serum of blood acting upon it for days at the temperature of the
body does not make the knots relax their hold. In this form the gut seems
almost a perfect material for the ligature under any circumstances in which it
is required.
‘Prepared catgut’ will, I hope, soon become a well-known article of com-
merce. But, for the sake of surgeons who may wish to prepare it for them-
selves, it is necessary to mention, in order to avoid disappointment, that the
essence of the process is the action of an emulsion of water and oil upon the
animal tissue. The same effect is produced upon the gut, though more slowly,
by an emulsion formed by shaking up simple olive oil and water, as by one
which contains carbolic acid. On the other hand, an oily solution of carbolic
acid without water has no effect upon the gut beyond making it antiseptic,
and if water be added only in the small proportion which the acid enables the oil
to dissolve, though the gut is rendered supple, and acquires a dark tint from the
colouring matter of the oil, it will be found, even after steeping for months in
such a solution, that when transferred to water it swells up and becomes soft,
opaque, and slippery, as if it had not been subjected to any preparation. How
it is that an emulsion produces this remarkable change in the molecular con-
stitution of the tissue I do not profess to understand. I was at first inclined
to regard it as a closer aggregation of the particles, brought about by a kind of
slow drying of the moistened gut in the oil, as the watery particles precipitate to
the bottom of the vessel; but, not to mention other circumstances opposed
H 2
100 OBSERVATIONS ON LIGATURE (OF ARTERIES
to this view, the oil remains turbid for a very long time, the finer particles of
water being extremely slow in precipitating, and if, after the lapse of weeks,
a piece of dry unprepared gut is suspended in it, the thread is soon rendered
soft and opaque by the very liquid in which gut which has been longer immersed
is growing constantly firmer and more transparent. It is necessary that the
gut be kept suspended so as not to touch the bottom of the vessel, for any parts
dipping into the layer of precipitated water would fail to undergo the change
desired. The vessel containing the emulsion should be left undisturbed, for
if the water is shaken up with the oil the process is retarded. An elevated
temperature of about 100° Fahr. seems for a while to promote the change, but
ultimately leaves the gut in an unsatisfactory state compared with that obtained
at an ordinary temperature. And conversely some portions of gut which I have
prepared lately (February 1870) in a room without a fire, in cold weather, at
a temperature of about 46°, were in one week already in a trustworthy con-
dition for surgical purposes. Hence the gut should be prepared in as cool
a place as possible. The longer it is kept in the emulsion, the better the gut
becomes. I once feared that it might in time grow too rigid for convenience, and
possibly brittle also; but experience shows that this is not the case. When
removed from the emulsion it soon dries in the air, but retains a considerable
portion of its carbolic acid for several hours, so that no apprehension need be
entertained of loss of its antiseptic property from exposure during the perform-
ance of an operation. In course of time it loses all the carbolic acid also, but
retains permanently its altered molecular condition. If thus kept dry, as may
prove the most convenient for the manufacturer on a large scale, it must be
steeped thoroughly in some antiseptic lotion before it is used. And for the
surgeon the most convenient way will probably be to keep it always in the
antiseptic emulsion, so as to be ready for use whenever it is required.
For tying an arterial trunk in its continuity, catgut at least as thick as
common purse-silk will be found best. But for ordinary wounds, where, if one
ligature happens to break, another can be easily applied, much finer kinds may
be employed, and are convenient from their smaller bulk. Several yards of
fine gut may be carried in the pocket-case, on a winder contained in a little
oil-tight silver capsule which I have had constructed for the purpose, as an
appendage to a caustic-holder.
AN ADDRESS ON THE CATGUT LIGATURE
Delivered before the Clinical Society of London, January 28, 1881.
[Clinical Society’s Transactions, vol. xiv.|
GENTLEMEN.—In thanking you for the great honour which you have con-
ferred upon me by my election to this chair, I do so with a peculiar feeling of
gratitude, because I am well aware that my personal share in the proceedings
of the Society has not been such as to entitle me to hope for so great a distinction
at your hands. I can only strive to discharge to the best of my ability the
important duties which your kindness has imposed.
In considering the choice of a subject for the inaugural address which is
expected from your President, I have felt myself precluded from presenting
a summary of the labours of the Society in the past, or from tendering advice
as to its conduct in the future, and, after consultation with some influential
members of the Council, I have decided to bring before you this evening a special
subject, which will, I trust, be thought not unworthy of the occasion, inasmuch
as, while it is still in an unsettled or transitional state, it is full of interest for
every practical surgeon, and at the same time,in some of its aspects, well
deserves the attention of the pathologist and the physician—I refer to the
catgut ligature. In adopting this course I feel it needful to crave your indul-
gence ; for the subject is a large one, and, in order to do it anything like justice,
I shall have to trespass for a considerable time on your attention.
The catgut ligature has in some respects exceeded my original hopes.
I feared that its advantages would be limited to wounds in which putrefaction
was avoided, and that, if septic suppuration took place in a wound in which
it was employed for securing the vessels, the ligatures would, sooner or later,
come away like little sloughs. Such, however, has not proved to be the case.
Whatever be the progress of the wound, we never see anything of the catgut ;
so that even surgeons who have not adopted strict antiseptic treatment have
been led to employ the new material in ordinary wounds. Under other circum-
stances, however, the catgut has often led to disappointment. We hear of
cases in which the Caesarian section has been performed, and all has gone on
well until the knots of the catgut with which the uterine wound was secured
have given way, and the patient’s death has been the result. Again, in ligature
of large arterial trunks in their continuity, several surgeons have met with
102 ON THE CATGUT LIGATURE
bitter disappointment, the case ending in disaster from secondary haemorrhage,
or the treatment proving abortive through the channel of the vessel becoming
opened up again at the site of the ligature. Hence many surgeons have been
induced to return to silk, even though using strict antiseptic treatment—render-
ing the silk aseptic by steeping it in a suitable lotion, and cutting the ends short.
This practice has, however, by no means proved uniformly successful. As an
instance of unsatisfactory result, I may mention a case which was recorded by
Mr. Clutton in the last volume of our Tvansactions. He tied the external
iliac artery with silk under strict antiseptic precautions, and the wound healed
within a week ; but, as I learned from a letter which he was good enough to
send me at the time, ‘six weeks after the operation a little blister formed, and
fluid began to escape, forming a small scab, and in three months the loop which
had been placed around the artery came away.’ Such a result was not at all
surprising to me, seeing that what induced me to try the animal ligature was
the discovery of a small abscess about the remains of a partially absorbed silk
thread which I had applied in the same manner as Mr. Clutton, and, as it so
happened, to the same artery. It can hardly be doubted that suppuration
proceeding from the immediate seat of the ligature must be a source of danger.
As an illustration of the mischief which a ligature of ordinary material may do,
I may mention a case of goitre in a young woman on whom I operated on the
28th of January last year. Itwas of moderate dimensions ; but the effect on
the respiration was so considerable that I determined to remove it, following
Dr. Patrick Heron Watson’s plan of preliminary deligation of the thyroid vessels
circumferentially to the tumour. If this be effectually done, the operation is
bloodless ; so that, as the laryngoscope applied by Dr. Felix Semon, who had
recommended the case to my care, showed that the anterior wall of the trachea
was pressed backwards considerably by the growth, I adopted a measure which
I believe would in all cases of removal of the thyroid prove advantageous,
namely, after the preliminary deligation of the vessels, I divided the tumour
in the middle line, so as, in the event of adhesion to the trachea, to be able to
remove the two halves of the growth at leisure, dissecting it off from the trachea
more or less completely as may be desired, leaving some portions at the adherent
parts, and thus avoiding the deadly risk of perforation of the air-passage. But
in order that the circumferential ligature of the thyroid vessels may be secure,
it is essential that the material employed should be very strong, so that the
tissues round about the tumour, including the vessels, may be thoroughly tight-
ened up. I possessed no catgut which I felt was resistant’ enough to bear the
full strength of my hands, and therefore I was compelled to use the hempen
? See ‘Observations on Ligature of Arteries on the Antiseptic System’ (p. 86 of this volume).
ON THE CATGUT LIGATURE 103
ligature—after, of course, carefully rendering it aseptic by means of carbolic
lotion. Six of these hempen ligatures were used—three on each side. During
the first eight days, everything went on in a typical fashion according to the
antiseptic method. There was a merely serous effusion, rapidly diminishing
in amount ; and we looked to the wound being healed in a few days more.
But on the ninth day there was seen to be a little something of purulence mingled
with the discharge ; and the pus afterwards became thicker, though always in
small quantity ; a little could be pressed out from each side ; and in a month,
one of the hempen ligatures made its escape. Six days later, four others of the
hempen threads came away altogether unaltered, as may be seen on one of the
cards on the table where I have exhibited them. I submitted them to careful
examination. They had a sour odour, and, applied to litmus paper, gave an
acid reaction, that is to say, the natural alkaline condition of the blood-serum
had been changed to acidity by some peculiar species of fermentation. On
examining them with the microscope, I found the interstices of the threads
of the hemp loaded with a form of organism, to which I believe I happened to
be the first to direct attention as to its mode of growth,’ and to which I gave
the name of Granuligera, occurring in groups of two, three, four, and so forth,
as distinguished from the chains of ordinary bacteria, and of which one species
at least has been since shown by Mr. Cheyne to occur very frequently in cases
treated antiseptically, without any interference with aseptic progress. I found
that the interstices of the threads of the hemp were loaded with these little
micrococci. It so happens that I have had the opportunity, within the last
few days, of obtaining a sample of these micrococci, thanks to Mr. Cheyne’s
kindness. He brought this flask, containing then a pure and perfectly trans-
parent organic infusion, to a case which I had operated on a fortnight before
by excision of the ankle. The skin had been unbroken, so that I was able to
operate antiseptically, and the case pursued a perfectly typical course. The
wounds, which were left gaping at the time of the operation, were filled with
blood-clot, which remained unaltered in appearance, though undoubtedly
organized by that time, more or less. A little piece of the blood-clot from one
of these wounds was introduced with careful antiseptic precautions into the
flask of clear fluid, and you see it is now turbid, and there is under the micro-
scope on the table a specimen of the little organism to which the turbidity is
due. But though, under ordinary circumstances, these micrococci may be
present, as Mr. Cheyne has abundantly shown, and as the excision of the ankle
I have just referred to illustrates, without causing any evil, yet there may be
circumstances in which they may prove mischievous ; and the case of goitre
* See Transactions of the Royal Society of Edinburgh, vol. xxvii, 1875 (see vol. i, p. 282).
104 ON (THE CATGUR LIGATURE
which I have been relating appears to have been one of these. The micrococci,
developing for a protracted period in the interstices of the hempen ligature,
produced their special fermentation of the serum in its most aggravated form.
The acid serum became a cause of irritation; and thus the ligatures, which
otherwise, being unirritating in their own substance, might have become encap-
suled, and in due time absorbed, became causes of suppuration. One of the
six ligatures still remained unaccounted for. In due time we sent the patient
home with a small sinus remaining, a little pus always discharging from it ;
but it was not until the middle of September that the last ligature came away,
altogether unaltered. Now, gentlemen, there is no doubt whatever that, if I had
had catgut which I could have trusted for the operation, the catgut ligatures
would have been disposed of within two or three weeks, and the healing, instead
of requiring eight months, would probably have been completed in a fortnight.
Here, then, we have an illustration of the great disadvantage which may arise,
even under antiseptic treatment, from the use of the ordinary forms of ligature.
Animal ligatures of another kind have been provided by Mr. Barwell, in
order to remove these difficulties, namely strips of the mingled yellow elastic
and unstriped muscular tissues which constitute the arterial wall, obtained by
cutting spirally the aorta of one of the larger animals. But, though fully admit-
ting the efficiency of these ligatures in his hands, I am given to understand
that their form and size render them by no means very convenient, and, inde-
pendently of this, I cannot but feel that it is unsatisfactory, if it can be avoided,
to have a special material for this particular object, and that it would be better,
if possible, to have the catgut in a thoroughly reliable condition. Catgut, of
which I have samples here, is to be had all over the world in abundance. It is
beautifully strong and smooth ; it is made of various sizes suitable for all surgical
requirements, and is extremely cheap. Wholesale, it is sold at 12s. per gross,
that is to say, one penny per hank. But, as it comes from the maker, it is
entirely unfit for the purposes of the surgeon. However beautiful it is in the
dry state, it becomes soft and pulpy soon after it has been placed in blood-
serum. In one of these glasses is a piece of unprepared catgut which was placed
in warm serum this morning, obtained from the blood of a cow, and within
half an hour it was in the condition in which it is at the present time—swollen,
soft, and pulpy. A knot tied upon it in its present state would hold as little
or scarcely better than would one on a piece of the slippery intestine from which
the catgut is derived. It is essential, in order to fit the catgut for the purposes of
the surgeon, that it be altered in its physical constitution so as to be no longer
liable to this softening effect by the serum of the blood. It is a remarkable
circumstance that the blood-serum softens catgut even more than water does.
ON THE CATGUT LIGATURE 105
It might have been expected, a priori, that a solution of a colloidal substance
like albumen would have been much less disposed than water to permeate and
soften an animal tissue like catgut ; but it is otherwise, and therefore we cannot
test the trustworthiness of catgut by steeping it in warm water, as I formerly
used to do. In order to be sure that a given specimen will answer the purpose
in so far as the knot is concerned, that it shall not slip, it is needful that we
should steep it in blood-serum, a somewhat troublesome process, as it involves
sending to a slaughter-house for blood.
The method of preparing catgut which I published long ago answers the
purpose very well, even for the ligature of arteries in their continuity, provided
certain conditions be complied with; such, at least, is my own experience.
This, indeed, has not been very extensive, but it has been sufficient to deserve
consideration. I have tied altogether nine large arteries in their continuity
with prepared catgut. Of these, one was a case of ligature of the carotid, in
a young woman, aged twenty-two, with a pulsating tumour below the angle
of the jaw, in the situation of a carotid aneurysm and with all the symptoms of
that disease. The application of the ligature reduced to a certain degree the
pulsation and the dimensions, but the further cure which we hoped for did not
take place. She left the hospital with a pulsating tumour; and I heard only
yesterday from the medical man under whose care she is in Scotland, that this
tumour, for which I tied the carotid artery in 1874, still exists as a pulsating
swelling, if anything, rather on the increase. But though, as regards the cure
of the disease, the ligature was unsatisfactory, nothing could be more beautiful
in its effect as respects the healing of the wound without suppuration, and the
permanent obstruction of the vessel at the seat of ligature.
A case of traumatic arterio-venous aneurysm of the temporal artery, in
a young man lately under my care in King’s College Hospital, may be men-
tioned in this category, partly because the greatly dilated condition which the
naturally small artery had assumed brought it up towards the dimensions of
a large trunk, and partly because the concurrent ligature of the largely dilated
veins would, without antiseptic means, have been justly regarded as of con-
siderable danger. The others were all cases of ligature of the femoral. Six
were popliteal aneurysms. Four of these presented nothing deserving of special
remark. One was a diffuse aneurysm, extending up to the junction of the lower
and middle thirds of the thigh, and the other was an enormous diffuse aneurysm
reaching up to Poupart’s ligament, so that it was necessary for me to tie the
femoral artery about the situation of the ordinary origin of the profunda, and
even there my incision opened into the aneurysmal clots.
The last case that remains to be mentioned was a large arterio-venous
LISTER II I
106 ON: THE CATGUT EIGATURE
aneurysm of the upper part of the femoral, of idiopathic origin. This case was
of such special interest that I hope, on a future occasion, to make it the subject
of a paper before this Society. In all these cases, except two, catgut prepared
by the old method was employed, and in all these nine cases the result was
satisfactory, and recovery perfect, except as regards the poor young woman
who has still the pulsating tumour in her neck
As to the mode of applying the ligature, I have always used a single reef-
knot with short-cut ends, tying it sufficiently tightly to cause the giving way
of the internal and middle coats. This latter point is not, perhaps, essential,
as I long ago surmised,’ and as Mr. Barwell’s experience with his aortic bands
appears to indicate. But if, as is the case with catgut, the form of the ligature
admits of it, the injury done to the deeper tunics is, I believe, advantageous,
by leading to a salutary corroborative process of repair.
Why, it may naturally be asked, has my own experience been more satis-
factory with the catgut ligature than that of many other surgeons? There
are, I believe, two reasons for this. One is that I have never ventured to tie
an artery of considerable size in its continuity without having taken pains to
ascertain that the catgut was of thoroughly reliable material ; and the other
reason is that I have adopted strict antiseptic means of treatment, not only
during the earlier stages of the case, but to the last. So long as any part of
the wound remains unhealed, antiseptic treatment of the strictest kind ought,
I believe, to be employed. Even though the sore may seem to be superficial,
there may still exist a sinus leading down to the site of the ligature; and if
ordinary treatment, as distinguished from antiseptic, be employed, down this
sinus the septic process may advance and invade the ligature, and lead at
last to disaster from haemorrhage. I know that this has actually taken place.
But although the catgut prepared after the old method answers very well
if it be in proper condition, there is this great objection to that method: that
it requires a long time in order to produce the requisite quality. At least two
months are needed to make the ligature at all trustworthy. It is better at the end
of six months, and still better at the end of a year. I possess catgut prepared
in this way twelve years old. I have brought here a sample of such catgut,
which has been steeping in warm blood-serum since this morning, and it will
be seen that it remains translucent, and is comparatively firm, instead of being
opaque and soft, like the unprepared catgut in the same serum.
Now, the length of time that the present method requires is a very serious
objection. It places the surgeon who has not prepared the catgut for himself,
and kept it for a long time, at the mercy of the person who supplies it; and
* Cf. p. 98 of this volume.
ON THE CATGUT LIGATURE 107
the person who supplies it, not being aware of the enormous importance of the
question of time, if he happens to run out of that which has been long prepared,
will sell what has been only a short time in the preparing liquid, and is, in con-
sequence, altogether untrustworthy. A case illustrating this point occurred
last year in my practice at King’s College Hospital. A patient was admitted
who had met with a severe wound on the ulnar side of the forearm, at the anterior
aspect. The ulnar artery had been divided. This had been secured by my
house surgeon, who had also tied with catgut the corresponding ends of the
various tendons that had been severed. But, when I saw the patient next
day, I found that he could not feel with his little finger and the adjacent side
of the ring finger, and, therefore, it was evident that his ulnar nerve also had
been divided, and my house surgeon had not thought of attending to the ulnar
nerve. I therefore cut the stitches in the skin, and proceeded to explore the
deeper parts of the wound, in order to find the ends of the divided nerve, and
tie them also together with catgut; and I found that all the catgut sutures
with which the ends of the several tendons had been tied together were lying
absolutely loose ; the knots had slipped within the twenty-four hours; and
yet this catgut had been supplied by one of our ordinary instrument-makers.
He had sent us what had not been sufficiently long prepared. I took care to
use proper catgut for the ulnar nerve; and the patient left the hospital with
restored sensation in the fingers. The length of time that it requires is, there-
fore, an exceedingly serious objection to the present method of preparation ;
and one great object which I have had in view, in a series of experiments on
this subject, has been to devise a means, if possible, of preparation within a short
time. These experiments—it may seem almost ludicrous to say so—have
occupied two years of my leisure in the past, some time ago; and, after being
interrupted by an accidental circumstance, have been continued in a more
desultory manner since ; but at length I feel myself justified in bringing before
you a new mode of preparation, by which the catgut may in a short period be
brought into a perfectly reliable condition.
But before I allude to these experiments, which I must endeavour to do
in a short compass—I should weary you if I were to bring a large proportion
of my facts before you, though I may say, out of the hundreds of experiments
I have performed on the subject, I have never performed one which has not
added something to my knowledge of it—before referring to these experiments,
I wish to say a few words as to what catgut is. Catgut, as you are all doubtless
aware, is prepared from the small intestine of the sheep. The gut is treated
in what seems an exceedingly rude manner for so delicate a structure. It Is
scraped with some blunt instrument, such as the back of a knife, over a board ;
T2
108 ON THE CATGOT iGATURE
and by this means, as the people express it, the dirt is scraped out. That which
these persons call the dirt is the exquisite and complicated structure of the
intestinal mucous membrane. But while the mucous membrane is scraped out
from within, there is also scraped off from without, the circular coat of muscular
fibres. The result comes to be that the intestine is converted into a compara-
tively unsubstantial material, consisting of two parts, or bands, one more slender
than the other. When the intestine is stripped from the mesentery by the
butcher, the peritoneal covering of the gut shrinks into a narrow strip, and
this, with some longitudinal fibres, constitutes the more slender of the two
parts to which the intestine is reduced by the process of scraping. The other
part is the essential material from which the catgut is prepared, and this is
neither more nor less than the submucous cellular coat of the intestine. When
I first visited a catgut manufactory I was astonished to find that, after this
scraping process, the intestine could be blown up still as a continuous tube,
as you see can be done with this specimen, which has been treated in the manner
I have described. This translucent membranous tube isa beautiful anatomical
preparation of the submucous cellular tissue, though made in so rude a fashion.
This coat of the intestine, which in the sheep has such extraordinary toughness,
is the material out of which the catgut is prepared. For what the manufacturer
terms the ‘ ones ’—the thicker form of ordinary catgut—all that is done is to
twist the entire tube by means of a wheel, like a rope in a rope-walk, up to
a considerable degree of tightness, and then allow it to dry. It is afterwards
exposed to the fumes of burning sulphur, and for some more special purposes
it is bleached by the action of potash. But the essential thing is the twisting
and drying. It can be manufactured without sulphur, as well as without potash.
Some specimens which I have here were made by means of water only, without
the use of any other ingredient. This exceedingly beautiful material, as fine
and smooth as a horsehair, is nothing but the animal tissue twisted and dried.
For the finer kinds the submucous coat is split up by means of razor blades, more
or less numerous, according to the degree of splitting required, connected with
a conical piece of wood which is pushed along the tube.
Such, then, is the material with which we have to deal. The first of the
more recent experiments which I performed with reference to it was made with
the view of ascertaining, if possible, what part the water played in the ingredi-
ents used for the preparation by our old method. If I steep unprepared catgut
in a mixture of dry carbolic acid and oil, however long it be so steeped, although
it will be of course abundantly aseptic, it remains utterly unfit for the purposes
of the surgeon ; a knot upon it would still slip in a wound. But if, instead of
using carbolic acid in the crystalline state, we use carbolic acid which has been
ON THE CATGUT LIGATURE 109
liquefied by the addition of a little water, we get in course of time a properly
prepared catgut. I wished to ascertain how much water was required. The
carbolic acid would enable oil to dissolve a certain amount of water; would
that amount of water be sufficient which carbolic acid enables oil to dissolve ?
Accordingly, I prepared jars of carbolic oil, some containing the full amount
of water we had used hitherto, some a smaller quantity, and some none at all,
and placed in them portions of the same hank of catgut. In due time I pro-
ceeded to examine the result, by taking portions of gut and putting them into
warm water and leaving them for a while, in order to ascertain how the knots
would hold. To my great surprise, I found that which had been steeping in
the carbolic acid and oil without any water just as good as that which was in
the carbolic acid and oil with the water. This was contrary to distinct previous
experience. Reflecting on the matter, I saw that the only possible explanation
was that the catgut was already, so to speak, prepared before I put it in the
liquid. Now it so happened that the catgut I had used was several years old ;
and it turned out that mere age of the catgut prepares it ; that in proportion
to its age it is rendered less liable tobe softened by water or by blood-serum
and a knot tied upon it will hold better. And thus I had for the first time,
I believe, scientific evidence of the truth of what is popularly spoken of as the
‘seasoning’ of various articles made of animal products. I asked a person
who sold violin strings if there was any result from keeping the strings a long
time. He replied that the only result he knew of was that they would probably
get rotten. But it so happened just about that time there came an old fiddler
to amuse the patients in the Royal Infirmary, Edinburgh, at Christmas time.
The weather was wet, and he said that his fiddle would not work properly because
the fiddle-strings were not properly seasoned. So he was aware that fiddle-
strings, which of course are catgut, are liable to seasoning, and require it. The
knowledge of this effect of the mere lapse of time was very important, because
it enabled me to explain the success that I had had in my earlier experience
with catgut before I knew at all the proper mode of preparing it. I look back
with horror at some of my early procedures with catgut. I have operated, for
example, on an irreducible ventral hernia, opened the sac, divided the adhesion,
returned the protruding intestines, stitched up the mouth of the sac with catgut,
and then applied stitches at considerable intervals in the skin. All went per-
fectly well; but the mode of preparation that I then used, if I had worked
with catgut recently made, must have led, in such a case, to utter disaster ;
the knots must have slipped in a few hours, and the intestines must have been
protruded through the wound.
I need hardly say this mode of preparation, interesting though it is, would
ILO ON THE CATGUY LIGATURE
not be satisfactory ; 1t would only have, in a more aggravated form, the incon-
venience of the extremely long period which our old method demands. Besides
that, it by no means fulfils all the conditions that are required for a perfectly
satisfactory state of the catgut for surgical purposes. These conditions I will
now mention. In the first place, I have spoken of a short period of preparation.
This is very desirable. Then it is essential that the catgut should have proper
strength, so as to bear any reasonable strain that the human hands can put
upon it, in the thicker forms, as when used, for instance, in such cases as the
circumferential ligature of the thyroid vessels in the removal of a goitre, or for
securing the pedicle in ovariotomy. And it is not sufficient that it should be
strong to start with ; it is easy to get catgut strong in the dry state ; it is neces-
sary that it should be strong after steeping in blood-serum for a while. Take,
for example, the case of tumour of the thyroid. I employed six ligatures, and
in a former case, where the tumour was larger, I thought it prudent to pass
as many as eight, so as to subdivide more the mass that had to be tied; but
it is not convenient to tie each of these ligatures as soon as it is passed, and
the process of passing takes a considerable time. Now it would be a very sad
thing if the residence of the catgut among the tissues soaked with serum for
a few minutes, or even a quarter of an hour, should render it so soft that it
should give way when we put the strain of the hands upon it. That, then,
is another essential point, if the material is to be useful for all the purposes
for which it is desired. Then, again, it is necessary that a knot tied upon it
should hold with absolute security, not merely in the first instance, but after
soaking for an unlimited time in blood-serum. It is further needful that it
should not be too rigid ; for, as we shall see immediately, it is possible for catgut
to be over-prepared ; in which case it may remain almost like a piece of wire
among the tissues, and ultimately, perhaps, come away by suppuration in
consequence of the mechanical irritation which it produces. But while the
animal juices must be able to soften it sufficiently to render it mechanically
unirritating, yet, on the other hand, it will not do for it to be too rapidly disposed
of by absorption. If it is to do duty for the ligature of an artery in its con-
tinuity in the immediate vicinity of some large branch, it must remain for a con-
siderable time of good strength, unabsorbed ; and, when it is at length absorbed,
it is desirable that it should be removed in such a manner that, while it is
reduced in thickness, it shall still, as long as any of it remains, retain its
tenacity.
Now, these are a series of conditions which, I assure you, it is not easy to
fulfil completely. I have in various experiments complied with some of them
easily enough, but failed in others. Sometimes I have succeeded with all but
ON THE CATGUT LIGATURE III
one, and one has baffled me. I have tried various materials, as you will naturally
suppose. One substance that suggested itself was tannic acid, so as to convert
the fibrous tissue of the catgut into leather. I succeeded well enough in some
respects with tannic acid applied in different ways, but in one respect I did
not succeed. I have not obtained by means of tannic acid a kind of catgut
that is not too speedily absorbed. Even a piece of kid-leather, cut into a suitable
shape for sutures, and rendered aseptic, became too rapidly absorbed.
Chromic acid was another agent which I very naturally tried on account of
its well-known effect in hardening tissues. Chromic acid alone does not work
very well; but I found that the addition of some other substances to it aided
its action very greatly. By adding, for instance, to the watery solution a little
glycerine, thus producing a reducing action on the chromic acid, we get a differ-
ent sort of liquid, which acts much more energetically on the catgut. I was
highly delighted with the results of the action of this mixture of chromic acid
and glycerine ; and just at this time (June 1876), it happened that Mr. Oliver
Pemberton, of Birmingham, applied to me for a piece of catgut, for the purpose
of ligaturing the external iliac artery in a remarkable case of three aneurysms
in one liimb—two in the femoral artery, and one in the popliteal. I thought
I could not do better than send him a piece of my recently prepared chromic
catgut. I didso; anda month afterwards he wrote to me, saying that nothing
could be more satisfactory than the result. He had operated antiseptically ;
the wound had united by first intention ; and, so far as the case could go well,
all had gone well. There was, indeed, gangrene of the lower part of the leg,
which Mr. Pemberton had predicted would occur in consequence of the existence
of four successive obstructions in the course of the arterial channel; viz. the
ligature and three solid aneurysms. But the case, under proper management,
was doing well. Four weeks later, however, Mr. Pemberton wrote to me again,
telling me that, soon after his last report, the patient had begun to show signs of
suppuration about the seat of the wound. After a while the abscess opened
in the cicatrix, and one day the ligature which he had placed on the artery
was found lying unaltered on the granulations.1_ It is now on one of the cards
before you—an over-prepared ligature, which had come away, rigid and wire-
like, making its way out, as a piece of glass might have done, by mechanical
irritation. This opened my eyes for the first time to the possibility of having
catgut over-prepared. This over-preparation by means of chromic acid 1s,
I understand, to be found illustrated in a large German school at the present
time. I have been told by an American physician, who has lately been in
London after spending some time at that school, that the catgut ligatures come
* For an account of this case by Mr. Pemberton, see Lancet, August 4, 1877.
112 ON THE CATGUT LIGADURE
away from all wounds to which they are applied in that clinique. They count
the ligatures as they put them on, and invariably see them all before the case
is done with. The catgut has been over-prepared.
It is by means of chromic acid, however, that I have at length arrived at
a result which appears to satisfy all our conditions. But, before speaking of
the new method, I wish to say a few words more with regard to the old. To
what is it that it owes its virtue ? In this bottle is some catgut which has been
nearly ten months in our old preparing liquid—namely, one part of carbolic
acid which has been liquefied by means of water, to five parts of olive oil. In
this other vessel again we have catgut which has been the same length of time
in a solution of carbolic acid in water. Water will only take up about one-
twentieth part of its weight of carbolic acid ; but the effect produced upon the
catgut by the watery solution is very much greater than that brought about
by the four times stronger oily solution. In the former case, as you can see,
the catgut is almost black, a sort of purple black ; while the other is compara-
tively pale, very little altered from its original colour. This circumstance shows
two things. In the first place the effect of the watery solution of carbolic acid
upon the catgut explains the efficacy of the water in our old method. It is the
watery solution of carbolic acid in the liquid of the old method that is the effec-
tive agent. But in the second place we see that, when the watery solution is
mixed with oil, the fact that it is so mixed limits and checks its operation. If
catgut is kept in the watery solution only, there seems to be no limit to the
degree of continuous preparation of the gut—so that it becomes more and more
dark in colour, and more and more difficult of absorption by the tissues. It is
otherwise when the watery solution is blended with the oil. Though the process
does go on for many months, there is a time when it comes to a standstill.
You need not fear that catgut prepared by the old plan is ever over-prepared.
There is a specimen on the table, which, at the end of twelve years, is as limp,
after steeping for a while in blood-serum, as it would have been at the end of
a single year. Therefore, we possess in the carbolic oil a means of checking
any mode of preparation that we may adopt, keeping it from that time forward
not materially further prepared ; while at the same time the large proportion
of the carbolic acid to the oil (I to 5) ensures the catgut being maintained
perfectly aseptic.
The method of preparation which I have now the honour to bring before
you is the following. I dissolve one part of chromic acid in 4,000 parts of dis-
tilled water, and add to the solution 200 parts of pure carbolic acid, or absolute
phenol. In other words, I use a I to 20 watery solution of carbolic acid; only
that the carbolic acid is dissolved, not in pure water, but in an exceedingly
ON THE CATGUT LIGATURE 113
dilute solution of chromic acid. But minute as is the quantity of the chromic
acid, it exerts, when in conjunction with carbolic acid, a most powerful influence
upon the gut. The first effect of the addition of the carbolic acid to the chromic
solution is to change its pale yellow colour to a rich golden tint. But if the
liquid is allowed to stand without the introduction of the catgut, it changes
in the course of a few hours to a dingy reddish-brown in consequence of some
mutual reaction of the two acids, and a certain amount of grey precipitate is
formed. If, however, catgut about equal in weight to the carbolic acid is added
as soon as the ingredients are mixed, the liquid retains its brightness, and the
only change observed is a gradual diminution of the depth of the yellow colour ;
the precipitate, if it still occurs, taking place into the substance of the catgut.
As soon, therefore, as the preparing liquid has been made, catgut equal in weight
to the phenol is introduced into it. If you have too large a proportion of catgut,
it will not be sufficiently prepared ; if you have too small a quantity, it may
run the risk of being over-prepared.’ At the end of forty-eight hours the chromic
element of the liquid has nearly spent itself, and the process of preparation is
complete. The catgut is then taken out of the solution and dried, and, when
dry, placed in 1 to 5 carbolic oil ; it is then fit for use. I have here a sample of
catgut prepared by this method. Although it has been steeped in warm blood-
serum since this morning at eleven o’clock, it is still translucent and firm without
being rigid, and a reef-knot tied upon it holds with the most perfect security.
The strength of the catgut depends upon different circumstances. In the
first place, sheep differ as to the strength of their intestines ; and the catgut-
maker, if he understands his business, will insist upon having his raw material
of a proper kind. In the next place, the intestines must not be allowed to
putrefy—they must be used when quite fresh. For these things you must,
of course, rely upon the maker of the catgut. In the next place, the preparing
liquid causes a certain amount of softening of the catgut, and if it is introduced
in loose hanks, this will tend to produce a little uncoiling of the twisted cord,
and a still greater degree of uncoiling will take place during drying. It is of
very great importance that this should not occur, because it involves weakening
of the thread, and that in different degrees in different parts; and this may
lead to the gut giving way when you subject it to a strain. The catgut, then,
should be prepared on the stretch both when it is put to soak and when it is
put to dry.
I need not enter into the mode in which this can be done by the manu-
facturer. I may only say this, that the surgeon who wishes to prepare it himself
* A moderate excess of the liquid, not exceeding twice the prescribed amount, does not produce
any serious degree of over-preparation.
114 ON THE CATGUYT TIGATURE
may do it in different ways. For instance, he may take two large test-tubes,
one a little larger than the other, and he may wind the catgut on the smaller
tube, fixing one end by sealing-wax, winding it round, then bringing it up again,
and fixing the other end also with sealing wax at a higher level than the liquid
will reach, putting sufficient liquid into the larger test-tube, and introducing
the smaller test-tube with the catgut wound round it, and containing a little
shot or other heavy material to keep it down in the liquid. After forty-eight
hours he takes out the smaller test-tube, and leaves it till the catgut is com-
pletely dry. I merely mention this as an illustration, and also as furnishing
a hint to some surgeons in private practice who may desire to prepare the catgut
themselves. Or a couple of gallipots, one larger than the other, will do just as
well. But, as I have already said, the principal uncoiling takes place during
drying ; and for all ordinary purposes a sufficiently good article is got by putting
the catgut loose into the liquid, and making it dry on the stretch, by tying the
ends of each hank to two fixed points in a room.
In the dry state, catgut prepared by this method is as strong as need be.
As to strength in the condition after steeping in blood-serum, I confess it is
only this very day that I have obtained evidence that catgut thus prepared
is really all that we can desire in that respect. The catgut of the hank from
which this specimen was taken measured in the dry state 22-hundredths of an
inch in diameter, and broke at 13 1b. 60z. I have found by experiment that
ro lb. is the utmost strain that my arms are able to put upon a cord. Thirteen
pounds six ounces, then, is amply sufficient ; while, at the same time, the catgut
is not at all too large for going into the eye of an aneurysm-needle. Having
obtained, the other day, some fresh blood of a cow from the slaughter-house,
I took some of the serum to-day, and put two pieces of this same hank of catgut
in the serum, and placed it in a stoppered bottle in a warm box at a temperature
of 98° Fahr. After more than half an hour I tested the breaking strain (I
must not stop to explain how that is done’), and I found that the breaking
strain of the same catgut which in the dry state had broken at 13 lb. 6 oz.
was Ir lb. 40z.; that is, though suppled by the serum, it had only lost in
* The mode of proceeding was as follows. A piece of steel, of horseshoe form, is suspended by
a ring on the middle of its convexity, so that the horns of the horseshoe are dependent ; these horns
being perforated for the reception of a cylindrical bolt of steel, which thus lies horizontally, and can
be removed at pleasure. A piece of the catgut having been tied in a double reef-knot, the bolt is partially
withdrawn, and is readjusted after the noose of the catgut has been slipped over it. Into the lower
part of the catgut-ring thus suspended is passed the upper end of a pot-hook, to the lower part of which
are attached weights approaching what the gut is likely to bear, and also an empty bag, into which
shot is poured till the cord gives way. The shot is weighed ; and the result, added to the other weights,
gives double the breaking strain of the gut; for, as the cylindrical bolt works with perfect smoothness
in its bed, it adjusts itself so as to prevent inequality of strain in the two sides of the catgut-ring, which
thus take an exactly equal share in sustaining the weight.
ON THE CATGUT LIGATURE II5
strength two pounds out of thirteen. I think that is really all that can be
desired.
[A few days after the delivery of this address I made some experiments
regarding the strength of the new gut after longer periods of immersion, using
the serum which I had before employed for the purpose, and which, being
derived from blood taken from a cow with antiseptic precautions, remained still
perfectly sweet. I first tried the specimen of gut twelve years old, prepared
by the old method, a portion of which I exhibited at the meeting steeped in
serum. It is comparatively slender gut, having little more than half the thick-
ness of the chromic gut with which I before experimented, the average diameter
being 12-hundredths of aninch. Two trials of it in the dry state gave 5 lb. g oz.
as the average breaking strain; and two other pieces, after steeping half an
hour in the warm serum, broke at 31b. 140z. In other words, this especially
well-seasoned sample of what the old method could provide was deprived by
warm serum of about one-third of its strength in half an hour. I next tested
a piece of gut prepared three months ago by the new method, similar in thick-
ness to the other, viz. having an average diameter of 13-hundredths of an inch.
Four trials with it in the dry state gave an average breaking strain of 6 lb. 15 oz.
I then placed in the warm serum three other pieces of the same hank, after
measuring their diameters. One of these pieces, with diameter 13-hundredths
of an inch, tested after it had been one hour in the serum, broke at a strain of
5 lb. 13 0z. Another piece, which when dry measured decidedly less in diameter
than the first, was tried after being fourteen hours and a half in the serum,
when it also broke at 5 lb. 13 oz. A third piece, just 13-hundredths of an inch
in diameter when dry, was left in the warm serum for twenty-four hours, at the
end of which time it showed a breaking strain of 5 lb. to} oz. Thus the new
gut continued as strong, or nearly so, at the end of a day in the serum as it had
been after the lapse of an hour, and lost in the serum only about one-seventh
of its full strength in the dry state, a result corresponding very closely with
that obtained in the former experiment with the thicker chromic gut after
forty minutes’ immersion. At the same time, the new gut being considerably
stronger to start with than that prepared by the old method, its strength, after
steeping for twenty-four hours in warm serum, was greater than that of the old
kind in the dry state. ]
The only remaining condition to be considered regarding the new catgut,
is its suitable behaviour among the tissues. Before describing this, | must say
a few words regarding the manner in which catgut is absorbed. It has been
said of late by various persons that the catgut is dissolved by the serum. I must
confess that this is entirely contrary to my own experience. I have already
116 ON THE CATGUT LIGATURE
said that, in order to test the quality of catgut, you must have it steeped in
blood-serum. I have tested in this manner catgut prepared in various ways.
The serum has sometimes been putrid, sometimes it had no smell at all, and
sometimes it had a little odour. The serum has been kept about the temperature
of the body, but I have never seen the slightest indication of any chemical
solution of the catgut. Then, again, as to the behaviour of the catgut in the
body : suppose we use it as a stitch, if the catgut were disposed of as a matter
of chemical solution, we should expect that, when it is employed as a suture
and a piece of our protective is put over it, which is always kept moist with
Fic. 1.—In this woodcut, the suture referred to is represented magnified
five diameters. Its actual thickness was one-fiftieth of aninch. The part
between a and 0 is that which had been among the tissues.
serum perpetually oozing from the wound, the outer parts of the stitch, the
parts outside the skin, as well as the parts among the tissues, would show signs
of diminution. It is never so. The diminution is always absolutely limited to
the parts within the tissues. It is still more striking, as was suggested to me
by Mr. Cheyne, to consider the case of catgut used as a drain. There its very
function is to drain out the serum, and it is perpetually washed with it. You
might suppose that a stitch might perhaps become a little dry ; but here there
can be no mistake ; the serum from the wound is perpetually flowing over the
gut, yet, as in the case of the suture, we find the diminution of the catgut is
absolutely limited to the part within the tissues. This seems to me sufficient
evidence that it is not a question of mere chemical solution of the catgut, but of
disposal of the catgut in some way or other by the living textures.
ON THE CATGUT LIGATURE 117
Now, if we examine catgut in the process of diminution in the living body,
we find that it may be affected in one of two ways. If it has not been properly
prepared, the substance of the catgut becomes converted, in the course of a very
few days, into a soft pultaceous mass, which, when we examine it by a micro-
scope, we see consists of remains of the old cellular tissue of the submucous
coat, with the interstices among the fibres filled with cells of new formation.
The catgut tissue is infiltrated with young growing cells, and it is obvious it is
this infiltration which is the cause of the softening. But, on the other hand,
if the catgut is properly prepared, instead of being infiltrated by the cells of
new formation, it is only superficially eroded. In this stitch (Fig. 1) of catgut
prepared by the new method, removed from a wound thirteen days after its
introduction, you have a good example of this important fact. You will see
that, at the part which was among the tissues, there remains a very slender
residue of the catgut, all the rest having gone; but that slender residue was
pretty tough, and remained translucent, showing not even a superficial infiltra-
tion ; in short, having exactly the characters that we desire for catgut for the
ligature of an artery in its continuity, namely, that it shall not disappear too
rapidly, and that till the last, even though reduced in dimensions, it shall retain
some degree of its original firmness and tenacity. We know that antiseptic
treatment has shown that a piece of dead bone may be absorbed, provided it
be not putrid: the granulations that overlap it superficially may, so to speak,
erode it. It is not necessary for us now to consider how that is effected ; but
certainly, in some way or other, the granulations do what mere steeping in serum,
whether putrid or non-putrid, never would do. Never, I believe, would the
bone be dissolved by the serum ; and just as a non-putrid sequestrum is served
by the tissues, so is a well-prepared specimen of catgut ; it is superficially eroded.
I have here a stitch that I removed to-day from a wound made ten days ago—
a wound made for stretching the anterior crural nerve, which, as well as the
sciatic, was subjected to that treatment, in an aggravated case of sciatica.
You may see that, as yet, it shows no signs of erosion. We know by experience
that, if it were left three or four more days, we should probably find it eroded,
as the former specimen indicates; but until nearly a fortnight has elapsed
erosion does not begin. It then proceeds gradually, and, therefore, the thicker
the catgut the longer is the time required for its complete removal. We may
fairly consider that from a fortnight to three weeks is long enough for the
persistence of a ligature upon an artery in its continuity. [Three days later
I removed two remaining stitches in the case last referred to, and found
both of them slightly eroded superficially. |
I have brought with me this evening a preparation of the carotid artery
118 ON THE CATCQUT LIGATURE
of the calf in which I first established the fact of the substitution of new living
tissue for the dead old tissue of the catgut.1 If any gentleman will examine
the specimen after the meeting, he will see the ligatures of new formation in-
corporated with the external cellular coat of the artery. I have been strangely
misunderstood as having intended to convey the idea that the catgut, when
it becomes organized, comes to life again. Gentlemen, such an absurd notion
certainly never entered into my head; any more than, when I have spoken
of the organization of a blood-clot, I have meant by that expression to convey
the idea that the blood-clot becomes organized by its own inherent virtue.
I found the term ‘ organization’ ready to my hand; it was not a word of my
invention. It had been used with reference to lymph. Now, pathologists, in
speaking of lymph as becoming organized, did not, I suspect, mean by that
expression to imply that it was the lymph-substance that had the power of
self-organization, as distinguished from any influence that surrounding tissues
might exert upon it. So in the same way the expression ‘ vascularization of
lymph’ was used when it was universally believed by pathologists that the
new blood-vessels were formed only as loops from pre-existing blood-vessels.
Nowadays a different view may be taken, but the term ‘ vascularization of
lymph’ was employed without any notion that the lymph itself created the
blood-vessels. And so when I spoke of the organization of the blood-clot or
of catgut I never meant to convey the idea that the one or the other did the
work itself. As to the blood-clot, we know that if it remains free from putre-
faction among the tissues, it speedily becomes infiltrated with cells of new
formation. Whether the white corpuscles originally present in the clot take
any part in the formation of these new cells is a question now under discussion,
and one, I conceive, not at all prejudiced by the use of the term ‘ organization of
the blood-clot’. With regard to catgut, I think, if gentlemen would refer to
my original paper in the Lancet,? they would see that I stated very explicitly
that new tissue forms at the expense of the old, that the old tissue is absorbed
by the new, and that as the old is absorbed, new is put down in its place.
In conclusion, gentlemen, I venture to recommend the new chromic catgut
as in all respects deserving of your confidence, and at the same time to thank
you sincerely for the patient attention with which you have listened to this.
address.
* See p. 5 of this volume. > “Tpid:
NOTE ON THE PREPARATION OF CATGUT
FOR SURGICAL PURPOSES
[British Medical Journal, 1908, vol. i, p. 125.]
CaTGuT used for ligatures or sutures in surgery should fulfil various con-
ditions. It should, after soaking in water or blood-serum, be strong enough to
bear any strain to which it may be subjected, and should hold perfectly when
tied in a reef-knot. It must not be so rigid as it lies among the tissues as to
have any chance of working its way out by mechanical irritation. Nor should
it be too quickly absorbed, but should be consumed so slowly by the cells of
the new tissue that grows at its expense that, in case of the ligature of an arterial
trunk in its continuity, it may serve sufficiently long as a support for the sub-
stitute living thread in its embryonic condition. At the same time, it is essential
that the catgut be securely aseptic when applied.
Of the various substances which I have tried for the preparation of catgut,
that which has, with one exception, most nearly approached the ideal is sulphate
of chromium. The one exception is secure asepsis of the gut substance, this
salt being utterly untrustworthy as a germicide ; this defect is easily remedied
by the addition of a little corrosive sublimate, the powerful germicidal action of
which is not prevented by the chromium sulphate.
I was at one time discouraged from using chromium sulphate by finding
that it varied extremely in quality according to the manufacturer who supplied
it. Thus one sample got from a well-known firm proved quite insoluble in
water.' But a perfectly satisfactory result was obtained by adding solution of
sulphurous acid (Pharm. Brit.) to solution of chromic acid until the rich orange-
brown of the latter has passed through grass-green to the pure blue of chromium
sulphate. When this has occurred no more should be added, since free sulphurous
acid produces a precipitate with bichloride of mercury, and would thus, in
proportion to its amount, withdraw the germicide from solution when the two
liquids are mixed. In order to make quite sure that no free sulphurous acid is
present, it is well to keep a few drops of the chromic acid liquid in reserve, and
add them when the blue colour has appeared, so as to restore the green tint.
" I learn from Messrs. Morson (of Elm Street, Gray’s Inn Road), who have devoted a great deal ot
attention to this salt, that its most suitable form requires very great care in its preparation in ordet!
to avoid variation in its composition, and also that it is extremely hygroscopic, so that, unless it is very
carefully preserved, water in variable amount becomes associated with it, another cause of uncertainty
in its composition.
120 NOTE ON THE PREPARATION OF
Another point that requires attention arises from the fact that the P.B.
solution of sulphurous acid, as obtained from the chemist, is generally some-
what deficient in the amount of SO,, in consequence of loss by volatilization.
Hence it is necessary to use a smaller quantity of water for dissolving the chromic
acid than would otherwise be used ; and when the proper tint has been got,
add enough distilled water to bring the liquid to the requisite measure.
The following directions for preparing what is known as chromic (or some-
times sulpho-chromic) catgut in accordance with the above conditions were
given to manufacturing chemists in 1894, but have never yet been published :—
“The preparing liquid must be twenty times the weight of the catgut.
So for 40 grains of catgut 800 grains of preparing liquid are required. It is
made by mixing two liquids—namely, the chromium sulphate liquid and the
sublimate liquid.
“The sublimate liquid is :—
Corrosive sublimate . : 2 grains
Distilled water : , é iL 2G"
‘The sublimate may be dissolved by heat, but the solution must be
used cold.
“The chromium sulphate liquid is prepared thus :—
Chromicacid . : : 4 grains
Distilled water . : es Se
“Add to this as much sulphurous acid (P.B. solution) as gives a green
colour. If more is added the colour becomes blue, which shows that rather
too much sulphurous acid has been used. It is well to reserve a few drops of
the chromic-acid solution, to be added after the blue colour has just appeared
and restore it to green. Then enough distilled water is added to bring the
green liquid up to 480 grains. Then add the sublimate liquid.’
The catgut is kept twenty-four hours in the preparing liquid, and is then
dried on the stretch.
N.B.—It is essential that the CrO; and SO, solutions be mixed before the
HgCl, solution is added.
Catgut prepared in this way remains actively antiseptic in its substance for
an indefinite period, as was shown by the following experiment :—
Some slender hanks prepared three years previously, weighing 207 grains,
chopped into short segments, were placed in a small mortar and treated with
enough distilled water to cover them, 2,000 grains being required for the purpose.
The gut was then pressed firmly with a pestle, and the same was afterwards
done three times at intervals of about three hours. The gut and water were
CATGUT FOR SURGICAL PURPOSES I2I
then transferred to a stoppered bottle for seventeen hours, when the liquid was
poured off and filtered, being clear and almost colourless.
The germicidal property of the infusion was carefully tested by the late
Dr. Allan Macfadyen. In spite of the large amount of water used in preparing
it, he found that it destroyed the Streptococcus pyogenes in a quarter of an hour.
When diminished to half its bulk by evaporation 7m vacuoit killed Staphylococcus
pyogenes aureus in half an hour and deprived the resisting spores of anthrax of
vitality in two hours. When further reduced by one half, although the amount
of the liquid was still about twice that of the catgut to which it was applied, it
killed anthrax spores in an hour.
The following is Dr. Macfadyen’s account of these experiments :—
Liquid Tested.
Infusion of chromic catgut = 100 c.cm,
Orgamsms Used.
Bacillus anthracis, sporing potato culture.
Staphylococcus pyogenes aureus, laboratory stock culture.
Streptococcus pyogenes, virulent culture.
Methods.
Threads were soaked in emulsions of the above organisms and exposed
to the action of the above liquid for varying periods of time—fifteen minutes to
two hours. The threads were then washed in (1) sulphide of ammonium,
(2) distilled water (sterile), and placed on sloping agar and glycerine agar at
blood heat for seventy-two hours
RESULTS.
Liquid Unconcentrated.
Time + Hour 1 Hour 1 Hour § 2 Hours
Anthrax spores . = : : + aE
Staphylococcus pyogenes aureus . | + + + poor + slight
Streptococcus pyogenes . : fe) fe) O
Controls . F : : ‘ +
LISTER II Kk
I22
THE PREPARATION OF CATGUT FOR SURGICAL PURPOSES
Liquid Reduced to Half its Bulk.
Time + Hour | 4 Hour 1 Hour | 2 Hours
Anthrax spores + + + O
Staphylococcus pyogenes aureus . ? fe) O fe)
Streptococcus pyogenes . fe) fe) fe) O
Controls + + 2b te
Liquid Reduced to Quarter Bulk.
Time + Hour | } Hour 1 Hour | 2 Hours
Anthrax spores + + fe) O
Staphylococcus pyogenes aureus . fe) fe) fe) O
Streptococcus pyogenes .
trustworthy germicidal liquid.
begun.
O
oO
But while the substance of the catgut is thus not only aseptic but powerfully
antiseptic, its dry surface is liable to contamination by contact with septic
material, and it is essential that, before being used, it be washed with some
My practice has been to put the catgut, like the instruments, in I to 20
solution of carbolic acid about a quarter of an hour before the operation is
Any of the catgut that remains unused upon the reel may be afterwards
kept in a similar solution for any length of time without disadvantage.
The essential precaution of purifying the surface of the catgut is, I fear,
sometimes overlooked, the result being occasional suppuration attributed to
defect in the ligature, while it is really the fault of the surgeon.
ON THE EFFECTS OF THE ANTISEPTIC SYSTEM
OF TREATMENT UPON THE SALUBRITY OF A
SURGICAL HOSPITAL
[Lancet, 1870, vol. i, pp. 4, 40.]
THE antiseptic system of treatment has now been in operation sufficiently
long to enable us to form a fair estimate of its influence upon the salubrity of
a hospital.
Its effects upon the wards lately under my care in the Glasgow Royal
Infirmary were in the highest degree beneficial, converting them from some
of the most unhealthy in the kingdom into models of healthiness. The interests
of the public demand that this striking change should be made generally known ;
and in order to do justice to the subject, it is necessary, in the first place, to
allude shortly to the position and circumstances of the wards.
Each of the four surgeons of the infirmary had charge of three large wards,
two male and one female, besides several small ones for special cases. Of these,
the most important were the male accident ward and that for female patients,
the former containing the chief operation cases as well as those of injury. The
third main ward of each surgeon was devoted to chronic male cases, and was
in the old infirmary building ; but the other two were in the ‘ New Surgical
Hospital’, erected nine years ago. This consists of four stories above a base-
ment, each floor containing two large wards communicating with a central
staircase, besides several smaller apartments. The wards are spacious and
lofty, and in the centre of each are two open fireplaces, in a column which runs
straight up to the roof, conveying the chimneys of all the floors, and also
collateral ventilating shafts, which are warmed by the chimneys that accom-
pany them, and, communicating with various apertures in the ceilings, form
excellent means of carrying off the vitiated atmosphere, while fresh air is amply
supplied by numerous windows at both sides, the beds being placed in the
intervals between them, at a considerable distance from each other. Except
the serious defect that the water-closets in many cases open directly into the
wards, the system of construction seemed all that could be desired.
But, to the great disappointment of all concerned, this noble structure
proved extremely unhealthy. Pyaemia, erysipelas, and hospital gangrene soon
showed themselves, affecting, on the average, most severely those parts of the
AK 2
124 EFFECTS OF THE ANTISEPTIC TREATMENG
building nearest to the ground,’ including my male accident ward, which was
one of those on the ground-floor ; while my female ward was on the floor im-
mediately above. For several years I had the opportunity of making an observa-
tion of considerable, though melancholy, interest—viz. that in my accident
ward, when all or nearly all the beds contained patients with open sores, the
diseases which result from hospital atmosphere were sure to be present in an
aggravated form ; whereas, when a large proportion of the cases had no external
wound, the evils in question were greatly mitigated or entirely absent. This
appeared striking evidence that the emanations from foul discharges, as dis-
tinguished from the mere congregation of several human beings in the same
apartment, constitute the great source of mischief in a surgical hospital. Hence
I came to regard simple fractures, though almost destitute of professional
interest to myself and of little value for clinical instruction, as the greatest
blessings ; because, having no external wound, they diminished the proportion of
contaminating cases. At this period I was engaged in a perpetual contest with
the managing body, who, anxious to provide hospital accommodation for the
increasing population of Glasgow, for which the infirmary was by no means
adequate, were disposed to introduce additional beds beyond those contem-
plated in the original construction. It is, I believe, fairly attributable to the
firmness of my resistance in this matter that, though my patients suffered from
the evils alluded to in a way that was sickening and often heartrending, so as
to make me sometimes feel it a questionable privilege to be connected with the
institution, yet none of my wards ever assumed the frightful condition which
sometimes showed itself in other parts of the building, making it necessary to
shut them up entirely for a time. A crisis of this kind occurred rather more
than two years ago in the other male accident ward on the ground-floor, separated
from mine merely by a passage twelve feet broad ; where the mortality became
so excessive as to lead, not only to closing the ward, but to an investigation into
the cause of the evil, which was presumed to be some foul drain. An excavation
made with this view disclosed a state of things which seemed to explain suffh-
ciently the unhealthiness that had so long remained a mystery. A few inches
below the surface of the ground, on a level with the floors of the two lowest
male accident wards, with only the basement area, four feet wide, intervening,
was found the uppermost tier of a multitude of coffins, which had been placed
there at the time of the cholera epidemic of 1849, the corpses having undergone
so little change in the interval that the clothes they had on at the time of their
hurried burial were plainly distinguishable. The wonder now was, not that
* Statistics collected by desire of the managers established the fact that the ground-floor wards
were, on the average, most liable to pyaemia, whoever might be the surgeon in charge ; and that those
on the floor immediately above came next in this respect.
UPON SALUBRITY OF A SURGICAL HOSPITAL 125
these wards upon the ground-floor had been unhealthy, but that they had not
been absolutely pestilential. Yet at the very time when this shocking dis-
closure was being made, I was able to state, in an address which I delivered
to the meeting of the British Medical Association in Dublin,’ that during the
previous nine months, in which the antiseptic system had been fairly in operation
in my wards, not a single case of pyaemia, erysipelas, or hospital gangrene had
occurred in them ; and this, be it remembered, not only in the presence of con-
ditions likely to be pernicious, but at a time when the unhealthiness of other
parts of the same building was attracting the serious and anxious attention
of the managers. Supposing it justifiable to institute an experiment on such
a subject, it would be hardly possible to devise one more conclusive.
Having discovered this monstrous evil, the managers at once did all in
their power to correct it. The extent of the corrupting mass was so great that
it seemed out of the question to attempt its removal ; but it was freely treated
with carbolic acid and with quicklime, and an additional thickness of earth
was laid over it; and, further, a high wall at right angles with the end of the
building, and reaching up to the level of the first floor, so as necessarily to confine
the bad air most prejudicially, was pulled down, and an open iron railing was
substituted for it.
There can be no doubt that these measures must have proved salutary.
But even if it were admitted that they cured completely the particular evil
against which they were directed, it would still have to be confessed that the
situation of the surgical hospital has been far from satisfactory Besides having
along one of its sides the place of sepulture above alluded to, one end of the
building is conterminous with the old Cathedral churchyard, which is of large
size and much used, and in which the system of ‘ pit burial’ of paupers has
hitherto prevailed. I saw one of the pits some time since, having been requested
to report upon it by one of the civic authorities, who is also a manager of the
infirmary, and who, having accidentally discovered what was going on, at once
took steps to prevent for the future the occurrence of anything so disgraceful.
The pit, which was standing open for the reception of the next corpse, emitted
a horrid stench on the removal of some loose boards from its mouth. — Its
walls were formed, on three sides, of coffins piled one upon another in four
tiers, with the lateral interstices between them filled with human bones, the
coffins reaching up to within a few inches of the surface of the ground. This
was in a place immediately adjoining the patients’ airing ground, and a few
yards only from the windows of the surgical wards. And the pit which [ in-
spected seems to have been only one of many similar receptacles, for the Lancet
* See p. 45 of this volume.
126 EFFECTS OF fH ANTISEPIMG TREATMEN®
of September 25th contains a statement, copied from one of the Glasgow news-
papers, that ‘the Dean of Guild is said to have computed that five thousand
bodies were lying in pits, holding eighty each, in a state of decomposition, around
the infirmary’.t Just beyond the churchyard rises an eminence covered by
an extensive necropolis, which, however, from its greater distance, must have
comparatively little deleterious influence. When I add that what is called
the fever hospital,? also a long four-storied building, extends at mght angles
to the new surgical hospital, separated from it by only eight feet, and that the
entire infirmary, containing 584 beds, stands upon an area of two acres, and that
the institution is almost always full to overflowing,®? I have said enough to show
that the wards at my disposal have been sufficiently trying for any system of
surgical treatment. Yet, during the two years and a quarter that elapsed
between the Dublin meeting and the time of my leaving Glasgow for Edinburgh,
those wards continued in the main as healthy as they had been during the
previous nine months. Adding these two periods together, we have three years
of immunity from the ordinary evils of surgical hospitals, under circumstances
which, but for the antiseptic system, were especially calculated to produce
them.*
It may be well to mention in detail some facts regarding the comparative
frequency, before and after the period referred to, of the three diseases to which
surgical wards have hitherto been peculiarly liable—namely, pyaemia, erysipelas,
and hospital gangrene.
And first of pyaemia. This fearful disease used to occur principally in
two classes of cases—namely, compound fractures and the major amputations.
In compound fracture, it was so rife just before the introduction of the anti-
septic system that I had one of the sulphites administered internally as a pro-
phylactic, in accordance with Polli’s views, to every patient admitted with
this kind of injury, though I cannot say that we observed any distinct evidence
of advantage from the practice. But since I began to treat compound fractures
* I doubt if even my sense of the importance of the subject I am dealing with would have induced
me to enter into these disagreeable details, were I not able at the same time to bear my testimony to
the zealous manner in which the managers of the infirmary and the Town Council are exerting
themselves to correct the evils referred to. I understand that it is in contemplation to abolish entirely
intramural interment in Glasgow.
* About half the wards of the fever hospital are used for surgical cases.
* The rapid increase of Glasgow has rendered the infirmary, in spite of considerable additions of
late years, quite inadequate to the wants of the population ; but this evil will shortly be remedied by
the construction of a general hospital in connexion with the new College.
“ The antiseptic system was commenced nearly five years ago, but was for the first two years
employed almost exclusively in compound fractures and abscesses, which form but a small proportion
of surgical cases, so that the system cannot be said to have been in operation for more than three years
with reference to the subject of the present paper.
UPON SALUBRITY OF A SURGICAL HOSPITAL 127
on the antiseptic system, while no internal treatment has been used, I have not
had pyaemia in a single instance, although I have had in all thirty-two cases—
six in the forearm, five in the arm, eighteen in the leg, and three in the thigh.
These cases do not include those in which the injury was so great as to demand
immediate amputation. But it must be remarked that many of the limbs
saved were so severely injured that I should formerly have removed them without
hesitation. I almost forget the kind of considerations which used to determine
me to amputate under the old treatment; though I know that experience
taught us that it was only in comparatively mild cases that it was justifiable to
attempt to save the limb. Now, however, there is scarcely any amount or kind
of injury of bones, joints, or soft parts which I regard as inconsistent with con-
servative treatment, except such destruction of tissue as makes gangrene of the
limb inevitable as an immediate consequence.
But I may take this opportunity of observing that the attempt to save
a limb which, under ordinary treatment, would be subjected to immediate
amputation, ought not to be made lightly, or without a thorough acquaintance
with some trustworthy method of carrying out the antiseptic system ; by which
I mean, not the mere use of an antiseptic, however potent, but such management
of the case as shall effectually prevent the occurrence of putrefaction in the part
concerned. Without this such endeavours are far worse than useless ; for by
the time that local disturbance and constitutional disorder have made it apparent
that the antiseptic means have failed, the patient is so much prostrated by
irritation and blood-poisoning, that the operation, if performed, is probably
too late; and thus a loose and trifling style of ‘ giving the treatment a trial’
swells the death-rate at once of compound fracture and of amputation.
On the other hand, the surgeon will not on this account be justified in
contentedly pursuing the old practice of primary amputation ; for the antiseptic
means which it has been the main labour of the last five years of my life to
improve are now so satisfactory that any one duly impressed with the
importance of the subject, and devoting to it the study and practical attention
which it demands, will, with little trouble to himself, securely attain the results
which he desires. -
I lately visited my wards in Glasgow after an absence of some weeks, and
saw, amongst other cases, a compound dislocation of the ankle in a man who had
fallen about four feet from the platform at a railway station, and lighted on the
outer side of the right foot, which had been forced violently inwards, producing
a contused and lacerated wound, about four inches long, crossing the external
malleolus, and communicating with the articulation. When I saw the patient
the wound had been converted into a superficial sore, cicatrizing rapidly ; and
128 PREFECTS OF 2HE ANTISEPTICADREATMENT
there had been from first to last no deep-seated suppuration, nor any local or
constitutional disturbance. I asked my then house surgeon, Mr. James Coats,
with whom the most critical part of the treatment had rested, whether he could
reckon pretty securely upon such results. He replied, ‘ With certainty.’ I asked
the question for the sake of others who were standing by, having little doubt
what the answer would be, for when I left him in charge I felt sure that the
antiseptic management of the cases would be as satisfactorily conducted as if
I were present.
At the same time, it is only right to add, that when he entered upon his
office, though convinced of the truth of the theory of the antiseptic treatment,
he by no means felt the confidence in carrying it out which he has since acquired ;
and if an able man like Mr. Coats, imbued with the principles which I have
striven to establish, required some practical initiation into the subject before
he could be regarded as trustworthy, still more must such be the case with
those who, educated in the old system, and long habituated to its practice, have
to unlearn cherished ideas and instinctive habits.
But, returning from this digression, I must now speak of pyaemia after
the major amputations, before and after the introduction of the antiseptic
system.
The hospital records are unfortunately imperfect for one of the three years
immediately preceding the antiseptic period. In the other two years, the
mortality after amputations in my wards may be gathered from the following
tables :—
Before the Antiseptic Period.
1864
No. of
Seat of Amputation. Amputations. Recoveries. Deaths.
Shoulder I O I
Arm 3 I 2
Forearm 3 2 I
Thigh I I O
Leg 4 3 I
GNSS. be 2 I I
Ankle . 3 2 I
Totals 17 IO 7
1866
Arm : :
Elbow .
Forearm
A
=)
©
co)
oo |
olnueHOaR NHN
oluwao NOH
olrova OHH
Totals
OO
UPON SALUBRITY OF A SURGICAL HOSPITAL 129
On the other hand, we have—
During the Antiseptic Period.
1867
No. of
Seat of Amputation. Amputations. Recoveries. Deaths.
Arm I I 6)
Forearm 2 a .
Knee ° . a . ‘ ° 2 2 O
Leg . : . : ? ‘ ; F I I O
Ankle I I re)
Totals : : 7 7 O
1868
Shoulder . : : . : : I I Oo
Forearm : P : ; . : : 2 2. Oo
Thigh ; : : : ; . I O
Knee . . : : : : ; ; 8 5 3
Ankle . : : : : ; ; : 5 5 fo)
Totals . 5 : ; : : 17 14 3
1869
Shoulder 2 : 2 2 Oo
Arm 2 2 O
Forearm 2 I I
Thigh I fe) I
Knee 3 2 I
Leg 3 3 O
Ankle 3 2 fe)
Totals 16 3 3
Comparing the aggregate results, we have—
Before the antiseptic period, 16 deaths in 35 cases; or I death in every
2= cases.
During the antiseptic period, 6 deaths in 40 cases; or I death in every
62 cases.
These numbers are, no doubt, too small for a satisfactory statistical com-
parison ; but, when the details are considered, they are highly valuable with
reference to the question we are considering. This is especially the case with
amputation in the upper limb, where neither injuries requiring primary amputa-
tion nor the operations involve, as a general rule, much loss of blood or shock
to the system; so that, if death does occur, it is commonly the result of the
wound assuming unhealthy characters. It happens that there were twelve ampu-
tations altogether in the upper limb in each of the two periods referred to. Of
the twelve cases before the antiseptic period, no fewer than six died—a frightful
mortality certainly. And it is recorded that, of those six, four died of pyaemia
and one of hospital gangrene. Also that one of those which recovered had
pyaemia ; but, though the symptoms were well marked and severe, presented
an example, unhappily too rare, of recovery from the disease.
130 EFFECTS OF THE ANTISEPTIC TREATMENT?
Very different was the result of the corresponding amputations during the
antiseptic period. Eleven of the twelve cases recovered ; and the one death
which did occur was not the result of the operation, but took place in spite
of it, from pyaemia, which had resulted from fetid suppuration in a metacarpal
bone, and continued after I had removed the hand, in the faint hope that the
constitutional mischief might be thrown off when its original source had been
taken away. Some of the successful cases, I may add, were by no means favour-
able subjects for operation: as, for instance, a completely shattered hand in
a very aged person; the avulsion by machinery of nearly the entire arm, one
of the flaps of the amputation at the shoulder-joint being left contused and
lacerated as it had been formed by the injury ;? and, again, an enormous
osteoid cancer of the upper end of the humerus, involving the deltoid muscle,
and permitting only the formation of skin flaps, attended with profuse haemor-
rhage, in a patient already anaemic from the disease.
In the lower limb, twenty-eight amputations in all were performed during
the antiseptic period. Out of these, death took place in five ; but was generally
sufficiently accounted for by the severity of the case, as when the thigh was
amputated immediately below the hip-joint in a patient greatly exhausted by
haemorrhage from malignant disease; or, to take another example, when
primary amputation was performed at the knee on one side, and immediately
below it on the other, in a man who had sustained very severe injuries to both
legs, and had been transported a considerable distance by railway to Glasgow.
In one case only did pyaemia result from the operation—viz. after ampu-
tation at the knee in a young man of weakly constitution, where putrefaction
occurred in the stump through mismanagement. Here the symptoms of pyaemia
presented themselves during life, and the femoral vein was found loaded with
pus on dissection. When putrefaction occurs after such an operation, there
is no security against pyaemia, even in private practice ; and a single instance
of the kind in three years, and that in a feeble subject, is certainly no evidence
of any peculiarity in the hospital atmosphere.
In mentioning the fact that putrefaction occurred from mismanagement,
I do not wish to be understood as implying that it can always be avoided in
stumps. In the present state of surgical practice, this is far from being the
case. When sinuses exist in connexion with a diseased joint, putrefaction is
present in them at the outset ; and even if they are injected with an antiseptic
solution before the operation, it can never be certain that the liquid penetrates
to every recess of these often complicated passages, or destroys the vitality
of the putrefactive organisms, lurking, perhaps, in portions of lymph or slough.
* This case was treated by my colleague, Dr. Dunlop, during my temporary absence.
UPON SALUBRITY OF A SURGICAL HOSPITAL 131
And if a single such organism remain alive, it will propagate and spread in the
wound as soon as the antiseptic applied at the time of the operation has been
absorbed into the circulation ; and any external antiseptic dressing will, under
such circumstances, be of course entirely nugatory. It is, I suspect, for want
of bearing this point in mind that disappointment has often been experienced
in applying antiseptic treatment to amputations and excisions. The full possible
benefits of the system can never be obtained in such cases till it shall be deeply
impressed upon the profession and the public that abscesses, more especially
those in connexion with diseased joints, must never either be allowed to break
of themselves, or be opened without antiseptic precautions.’
I am bound to add that there is another respect in which the antiseptic
principle has not yet had justice done to it in the larger amputations in the
ower limb. Of all incised wounds, these have proved the most difficult to
manage ; and putrefaction has repeatedly occurred in my practice, even where
no sinuses were present. It was so in the two cases above referred 'to, of
amputation just below the hip-joint for malignant disease, and double primary
amputation for injury. Considering the condition of those patients on the day
after the operation, I believe both would have recovered had we succeeded in
avoiding putrefaction, which, apart altogether from the risk of pyaemia, terribly
aggravates formidable cases, like those, by the irritation and prostration which
it occasions. Hence we may fairly look for better results in the future from
amputation in the lower limb. For I am satisfied that the difficulties of the
antiseptic management are not insuperable. I have devoted much attention
to this branch of the subject during the last twelve months, and steady progress
has been made in it; so that the proportion of stumps in which healing has
taken place without any deep-seated suppuration has been markedly increasing,
and I anticipate that before long we shall be able to reckon with certainty on
the absence of putrefaction in all cases where sinuses are not present.
But to return to the subject of pyaemia. The two cases above alluded to
were the only instances of its occurrence in my department during the antiseptic
period. One of them requires further notice here. It belonged to a class of
injuries in which the benefits of the antiseptic system have been conspicuously
apparent—namely, severe contused wounds of the hand or foot, such as are
* The practice which I have found to answer best in amputations and excisions in parts affected
with sinuses is, after injecting the sinuses with a powerful antiseptic, to apply to the cut surface a pretty
strong solution cf chloride of zinc (say forty grains to an ounce of water), such as was recommended
by Mr. Campbell De Morgan, and then employ an external antiseptic dressing, in the hope, though never
in the certainty, that putrefaction will be avoided. Chloride of zinc, having the peculiarity of producing
a remarkably persistent antiseptic effect upon the cut surface, protects it during the dangerous period
preceding granulation, when the recently divided tissues are both sensitive and prone to absorption ; so
that even if putrefaction does occur, the risk of inflammation and pyaemia is greatly diminished.
132 EFFECTS OF THE ANSTISEPIICG TREATMEN®
very frequent in a great centre of manufacture like Glasgow. Formerly there
were no injuries more unsatisfactory to deal with. The uncertainty of the
extent of the damage inflicted by the contusion made it a most perplexing
question where amputation should be performed. On the one hand, if too
little was removed, sloughing of the flaps ensued, or diffuse suppurative inflam-
mation of the weakened tissues infiltrated with extravasated blood ; and, on the
other hand, 1f it was determined to avoid that error and to amputate through
perfectly sound tissues, an extravagantly large portion of the limb was often
sacrificed. It is therefore an unspeakable satisfaction to be able to avoid
amputation altogether in such cases, merely taking away such portions as may
be actually destroyed, and leaving the weakened tissues in the vicinity to recover
themselves quietly, instead of perishing under the irritating and poisoning
influence of putrefaction ; while any dead portions that may remain are absorbed
more or less completely, like the extravasated blood, and replaced by tissue of
new formation. If the history of all the contused wounds of the hands and
feet that have been treated in my wards during the last three years were
recorded, including many compound fractures not reckoned as such in our
classification and several compound dislocations, it would be enough to
convince the most sceptical of the advantages of the antiseptic system.
But the case to which I am now alluding was an exception to the general
rule of satisfactory progress. It was a severe injury to the hand from machinery.
My then house surgeon, who had only just entered upon his office, and had
not as yet the confidence in the antiseptic system which he soon afterwards
acquired, took it for granted that I should amputate the hand, and committed
the error of leaving it till my visit on the following day, without adopting effi-
cient antiseptic measures. When I saw the case I decided to try to save the
greater part of the hand, and endeavoured to correct the mistake which had
been made. Putrefaction, however, ensued, and after some days pyaemia
occurred, and continued, as before stated, in spite of amputation of the hand.
On dissecting the parts, one of the metacarpal bones was found split up, with
putrefactive suppuration developed in its interior. Under such circumstances
pyaemia might occur in a perfectly sound constitution and in the most healthy
atmosphere, just as, in Cruveilhier’s highly instructive experiment, suppurative
phlebitis of the femoral vein and its branches, exactly corresponding to that
which is seen in traumatic pyaemia, was induced in a healthy dog by intro-
ducing into the vessel a bit of wood which, from its porous nature, could not
but originate putrefaction."
* See Cruveilhier’s Anatomie Pathologique, livraison xi, where will also be found the records of
important experiments, proving how readily liquids introduced into the interior of bones pass into the
general circulation.
UPON SslUBRITY OF A SORGICAL HOSPITAL 133
Considering, then, the circumstances of the only two cases of pyaemia
which have occurred in my department during the three years of the antiseptic
period, I am justified in saying that the wards have been completely freed from
their former liability to this frightful scourge.
Next of erysipelas, a disease which, though not so fatal as pyaemia, used
not infrequently to occasion death amongst my patients. During the anti-
septic period several cases have been admitted into my wards from without,
but one only has originated in them. This occurred in a young man with disease
of the foot, accompanied by sinuses extending into the leg. I performed
amputation at the ankle, but putrefaction continued in the sinuses ; and after
the lapse of a considerable period erysipelas occurred in connexion with them.
He recovered from the complaint, and after a while went to his lodgings for
change of air, with the sinuses still unhealed, and subsequently had another
attack of erysipelas there, implying that the tendency to it was in his own system
rather than in the locality. That such was really the case was afterwards
fully demonstrated. The sinuses refusing to heal, and disease recurring in the
bone, he was readmitted under my care, and I performed amputation in the
leg above the sinuses. The stump healed without any deep-seated suppuration,
presenting a very good example of the result of a modification of Mr. Teale’s
method of amputation ; and I requested him to ascertain, by Mr. Teale’s plan
of introducing circular pieces of flannel into the socket of the artificial limb,
how much of his weight he could conveniently rest upon the end of the stump.
As he did not call to report the result on the day arranged, I inquired into the
cause, and learned that the stump had been seized with a third attack of
erysipelas, although perfectly cicatrized without sinus or sore of any kind.’
Thus, as regards erysipelas, our only exception to perfect immunity from the
disease during the three years was one that strikingly proves the rule.
It remains to speak of hospital gangrene. This was formerly both frequent
and severe amongst my patients. It often grievously marred the most pro-
mising results of surgery, and sometimes committed fearful ravages. Thus,
I have known a boy admitted with a small superficial wound near the elbow,
in which hospital gangrene occurring caused such destruction of tissue, deeply
as well as superficially, in spite of the most energetic treatment, that it became
necessary to amputate the limb. Now and then it led to a fatal result, as in
one of the amputations before referred to. In that case I removed the arm
at the shoulder-joint for injury in a boy, and for some time all went on well,
till I regarded him as perfectly safe; but hospital gangrene came on in the
* This case seems to me to possess considerable interest, as something intermediate—as it were
a connecting link—between traumatic and idiopathic erysipelas.
134 EFFECTS OF THE! ANPISEPTIC TREATMENT
stump, and, advancing insidiously in all directions, defied my best attempts
to check it, and had reached beyond the sternum before the poor fellow sank
exhausted from its effects.
The contrast under the antiseptic system has been most striking. For the
first nine months, as before mentioned, we had not a single case of the disease.
Since that time it has shown itself now and then, but in a mild form, invariably
yielding to treatment, never occurring in recent cases, but only in old sores
weakened by the influence of surrounding cicatrix. But even this has been
very rare, and I do not recollect more than one example of it during the last
year. In short, hospital gangrene, like pyaemia and erysipelas, may be said
to have been banished by the antiseptic system.
Such being the case, I have insensibly relaxed in different ways my former
vigilance regarding the wards. I have allowed cribs for children to be intro-
duced without remonstrance, having practically the effect of increasing the
number of beds for adults; and I have, in the pressure of deficient accommo-
dation, often permitted two children to be put in one bed—a thing which
I should formerly not have thought of. I used to make a point of having both
the large fires in each ward kept alight night and day during the heat of summer,
for the sake of making the ventilation as perfect as possible. But during the
last season the nurses were left to follow their inclination, and keep only one
of the fires lighted. I may add that my wards have remained during the three
years without the annual cleaning, which used to be thought essential. On
my asking the superintendent the reason for the omission, he replied that, as
those wards had continued healthy, and there was nothing dirty in their appear-
ance, it had seemed unnecessary to disturb them. Thus the wards have been
in various respects subjected to greater trial than usual, and yet have remained,
as I may repeat without any exaggeration, models of healthiness.
That such should have been the case under the unfavourable hygienic
conditions above referred to seems at first sight very surprising. The imme-
diate vicinity of a burying-ground such as has been described, together with the
position of the wards at the base of a hospital of four stories, with the air con-
fined by neighbouring buildings, may seem conditions utterly inconsistent with
health in the patients. That these circumstances were very unfavourable is
undoubtedly true; and that they were highly injurious before the antiseptic
period seems clearly indicated by our experience. But a little consideration
will show that it is not unreasonable to suppose them of secondary importance—
as agegravators of the evil, rather than the essential causes of it. The corpses in
the places of sepulture beside the infirmary were for the most part covered by
at least some inches of earth, which has a most powerful effect in checking the
UPON SALUBRITY OF A SURGICAL HOSPITAL 135
evolution of noxious effluvia ; and even the foul gases from the open pits were
perpetually diluted by the air with which they mingled, so that but a small
proportion of them would enter the wards ; and accordingly, when the patients
were cleared out for the purpose of the annual cleaning, there was nothing in
the wards to offend the nose. But the emanations from sores are poured
directly into the confined atmosphere in which the patients are ; and any one
familiar with the faint sickly smell commonly perceptible in surgical wards
under ordinary treatment, and still more with the stench which prevails at the
time of the daily dressing, will readily understand that putrid exhalations from
the patients may be a source of mischief, compared with which the other
circumstances alluded to may be of comparatively trifling consequence.
With the object of getting rid of this great evil as much as possible, I have
used antiseptic means, not only where they are of essential importance for the
treatment of the individual case concerned, as in recent wounds and abscesses,
but also in superficial sores. For though granulating surfaces will commonly
heal well enough under a putrid dressing (for such the cleanly water dressing
becomes within a few hours of its application), every case so treated furnishes
its quota to the vitiation of the general atmosphere of the ward. Hence, for
the sake of the inmates generally, it is obviously desirable that healing sores
should be dressed with some application which, while permitting, or, if possible,
favouring cicatrization, should prevent odour. For this purpose some dressing
unstimulating, but at the same time persistent in antiseptic action, is requisite,
—a combination which I have sought in various different forms to obtain, and,
of late more especially, with very satisfactory results, so that while the healing
of superficial sores proceeded with greater rapidity than under water dressing,
all my sixty patients might sometimes be dressed without the odour of putre-
faction being perceptible in one of them.
The result of this great change has been such as to demonstrate conclusively
that the exhalations from foul discharges are the essential source of the insalu-
brity of surgical wards; and that when this is effectually suppressed, other
conditions, which we are accustomed to regard as most pernicious, become
powerless to produce serious evil.
It is obvious that the facts recorded in this paper are of extreme importance
with reference to the vexed question of hospital construction. With the view
of assimilating the atmospheric condition of our large hospitals to that of a
private dwelling, it has been lately proposed to do away with them altogether
in their present form, and to substitute for them congeries of cast-iron cottages,
a plan
capable of being occasionally taken down, cleansed, and reconstructed
which, besides involving enormous expense, would interfere most seriously
136 ANTISEPTIC TREATMENT IN A SURGICAL HOSPITAL
with efficient supervision of the patients, and with the teaching of students
at the bedside. But from what has been related above, it is plain that no
material alteration of the existing system will be required. We have seen that
a degree of salubrity equal to that of the best private houses has been attained
in peculiarly unhealthy wards of a very large hospital, by simply enforcing
strict attention to the antiseptic principle. And, considering the circumstances
of those wards, it seems hardly too much to expect that the same beneficent
change which has passed over them will take place in all surgical hospitals,
when the principle shall be similarly recognised and acted on by the profession
generally. The antiseptic system is continually attracting more and more
attention in various parts of the world ; and, whether in the form which it has
now reached, or in some other and more perfect shape, its universal adoption
can be only a question of time. The noble institutions of which our country
is justly proud, admirably adapted alike for the treatment of the sick and the
instruction of the student, will then be cleared of the only blot that now attaches
to them—the malignant influence of impure atmosphere.
Edinburgh, December 1869.
REMARKS ON A CASE OF COMPOUND DISLOCA-
TIONS OP THE ANKLE: WITH OTHER INJURIES;
ILLUSTRATING THE ANTISEPTIC SYSTEM OF
TREATMENT
(Edinburgh, March 26, 1870 (Pamphlet). ]
This case was first alluded to as follows in a Lecture delivered on the 14th of
February 1870 :—
THE next case, Gentlemen, which I wish to bring under your notice, is
that of a labourer thirty years of age, who was seriously injured on a railway
three days ago. He was standing on the line, about a mile out of Edinburgh,
at 6 a.m., when he suddenly saw an engine close upon him coming at considerable
speed, and he had only just time to turn half round before it struck him on
the left shoulder and hurled him to the ground between the rails. On recovering
consciousness, he found himself unable to walk ; but about half an hour later,
his cap having been discovered above the buffers of the locomotive, the men
in charge of the engine went in search of the owner, and, finding him lying
helpless, conveyed him to the infirmary. When I saw him about 8.30 a.m.,
he was suffering considerably from shock; and he feared, from severe pain
which he felt in his chest, that he had received some serious internal injury—an
apprehension which has happily proved groundless. I found the left foot much
displaced inwards, and the external malleolus protruding through a vertical
wound in the integument two or three inches in length. The tip of the malleolus
had been broken off, and remained attached to the external lateral ligament ;
while the extremity of the protruding part was comminuted. The internal
malleolus was of course fractured, as a necessary condition of such a displace-
ment of the foot. Now, Gentlemen, if you were experienced surgeons, you
would know that this was a most formidable injury. Recoveries from it were
formerly exceptional. Mr. Syme informs me that at one time, on looking into
the hospital records, he found that the last fourteen cases of compound dis-
location of the ankle admitted into the infirmary had all ended fatally. He
therefore came to regard amputation at the ankle as the best treatment in
most cases; though he sometimes modified his practice so far as to content
himself with removing the end of the tibia, so converting the case into one of
excision of the ankle.
In our patient, however, neither of these procedures has been adopted.
For the purpose merely of facilitating the return of the protruding malleolus,
LISTER II L
138 CASE OF COMPOUND DISLOCATION OF THE ANKLE
I nipped off a portion of it with cutting-pliers, and, with the same object,
enlarged slightly with scissors the lower end of the rent in the skin, which op-
posed a barrier to its passage. But to all intents and purposes the dislocation
was simply reduced. The case, however, was treated antiseptically. Watery
solution of carbolic acid, as strong as it can be made (one part of the crystals
to twenty of water), was thrown into the joint with a syringe, the edges of the
skin being held together to prevent its escape and cause its penetration to all
the internal recesses of the wound; and this was further promoted by free
manipulation of the injured part while the fluid was still in the interior. There
was a time when we should have thought that to introduce an irritating liquid
like this into the ankle-joint would be to take an unwarrantable liberty with
the articulation. But we now understand that the transient irritation caused
by the antiseptic lotion is nothing compared with the abiding influence of the
far more acrid products of putrefaction. In the operation which you saw me
perform just now {the removal of a fatty tumour], a lotion of half the strength
(x to 40) was employed ; experience having proved that this is sufficient to ensure
destruction of the putrefactive organisms in a wound just made, and made by
the surgeon himself. But when the injury has been received some time before
you see the patient, and inflicted, as in the present instance, in a rude way,
involving the chance of foreign material having been introduced and mixed,
perhaps, with clots of blood lying in inaccessible recesses of the wound, it seems
wise to employ as strong a solution as water will produce. And as this will be
your only chance of acting upon putrefactive particles lodged in the interior—
as the work of their destruction must be done once for all at the outset—do
not be afraid of dealing very freely with the injured part in introducing the
germ poison. [It is a mistake to mingle spirit of wine or glycerine with the
watery solution used for injecting the wound. The admixture of either of
these materials with water containing a given amount of the acid in solution,
gives it a greater hold upon the acid, and renders the lotion more bland, and
at the same time more persistent in its action; and this may, under certain
circumstances, be very useful for the purpose of an external dressing. But
for the preliminary treatment of the interior of the wound an agent potent for
the moment, but transient, is called for, to kill the putrefactive organisms,
and, as soon as this is done, to leave the wound as speedily as possible to recover
from the inevitable irritation of the antiseptic ; and for this purpose no vehicle
seems better for the acid than simple water.?]| The liquid introduced having
been squeezed out, the process of injection and manipulation was performed
* The portion removed was covered at its deeper surface with articular cartilage.
* The remarks included within brackets were made on another occasion.
ILLUSTRATING THE ANTISEPTIC SYSTEM OF TREATMENT 139
a second time for greater security, and the skin in the vicinity having been
previously well washed with the lotion, to destroy organisms adhering to it or
to the hairs, an external dressing was applied, similar to that which you have
seen used after removal of the fatty tumour. Lac-plaster was wrapped in two
layers round the limb, from three or four inches above the upper extremity
of the wound to as far below its lower end—that is to say, extending well up
the leg and embracing the heel and instep; the foot meanwhile being held in
good position. A cloth, to absorb the blood and serum which would be discharged
from beneath the margins of the plaster, was then bandaged on, and a splint
applied to the inner aspect of the leg and foot. [The lac-plaster has been very
much improved of late, by being incorporated with a soft cloth, instead of being
spread upon starched calico. It is thus rendered beautifully flexible, and at
the same time much more durable, the cloth incorporated with it enabling it
to withstand any amount of wear and tear. But as in this form it is very thin,
it is well, where much discharge is anticipated, or when a long time is intended
to elapse between the dressings, to use it in two layers, so as to double the store
of the acid in the application. |
But, Gentlemen, the compound dislocation of the ankle was not the only
injury which this poor man received. Observing some blood about his hair,
I examined the head, and found four scalp-wounds, varying in length from two
to five inches, three of them exposing the bone, into which black dirt had been
ground—probably, as he suggests, by the fire-pan of the engine. We used to
reckon that when the bone was thus extensively exposed in a scalp-wound, and
subjected at the same time to such violence, the cure was pretty sure to prove
tedious, protracted by the exfoliation of osseous scales of greater or less thick-
ness. There was at the same time more or less risk of head symptoms or of
erysipelas. It is, therefore, very satisfactory in such cases to be able to reckon
on primary union under antiseptic management. The region occupied by the
wounds being extensive, the greater part of the scalp was shaved, and thoroughly
washed with the strong antiseptic lotion; and the wounds were treated just
like that at the ankle, except that their edges were approximated by antiseptic
sutures. [The material which I have used of late for this purpose is silk steeped
for a while in a mixture of melted bees-wax with a certain proportion of carbolic
acid—say a tenth part. As the silk is taken out of the hot liquid, it is drawn
through a dry cloth to remove the superfluous wax; after which it may be
wound on a reel, and kept in any close vessel. The wax, besides giving the knot
a better hold, prevents the antiseptic from being washed out of the thread,
and also, filling up the interstices of the fibres, renders the silk incapable of
imbibing stimulating liquids; and so confers an unirritating quality corre-
LZ
140 CASE OF COMPOUND) DISEGECA TION OF (TRE ANI
sponding to that of the metallic suture, over which the suppleness of the thread
gives it a great superiority.] When all had been stitched up, each wound was
once more injected with the strong watery solution, to correct any mischief
that might possibly have been introduced by regurgitation of blood that had
oozed into the cavity during the insertion of the stitches. A well-overlapping
cap of lac-plaster, in double layer, was then applied, surrounded by a cloth to
absorb discharge, secured by bandage and pins.
I cannot too strongly impress upon you the importance of having the
plaster extend freely beyond the wound at every part, so that the discharge
may have to travel a considerable distance beneath the impermeable antiseptic
layer before reaching the sources of mischief externally. It is only in this way
that you can guard securely against the spread of the putrefactive fermentation
into the wound. Yet there is nothing in the antiseptic treatment that I find
more apt to be neglected.
After I had left the patient, Dr. Cleaver [the house surgeon] discovered
a compound fracture of the right olecranon. The patient thinks he must have
fallen upon his elbow ; and in this he is no doubt correct, the fracture having
been thus caused by direct violence. The wound was not large (about an inch
in length), but, from the relations of the bone, it necessarily communicated
with the articulation. Here, then, was another injury, in itself sufficiently
serlous—a compound fracture into the elbow-joint. This Dr. Cleaver treated
in a manner similar to that in which I had dressed the ankle, and applied an
anterior splint to maintain extension of the elbow.
Now, Gentlemen, I do not hesitate to say that if our antiseptic means
succeed as such—that is to say, if putrefaction is prevented from occurring in
the wounds—neither of these severe injuries, the compound dislocation of the
ankle, the compound fracture into the elbow-joint, nor the scalp wounds expos-
ing and injuring the bone, will occasion either local or constitutional distur-
bance. You may perhaps think me bold to speak in this confident way at so
early a period of the case, at the beginning of the fourth day, the very time
when, under ordinary treatment, the region of the ankle would be red, swollen,
and painful, preliminary to suppuration, and the pulse rising, with other indica-
tions of increasing fever. But the progress of the patient already goes far to
justify me. All the injured parts are as yet in a perfectly quiet state, his pulse
is daily descending, his tongue is clean and moist, and he relishes his food, and
complains of no pain whatever, except that of the contusions of his chest and
shoulder. You cannot suspect me of exaggeration, for you have only to go to
the patient’s bed and inquire for yourselves ; and any of you who are disposed
to witness the dressing will see it done to-morrow at the visit hour.
ILLUSTRATING THE ANTISEPTIC SYSTEM OF TREATMENT 1,41
But besides the favourable condition of this patient hitherto, I have ample
experience to found upon. Since my attention was first drawn to antiseptic
surgery I have been concerned in four other cases of compound dislocation of
the ankle. One of them was treated in the Glasgow Infirmary just before
I left it. The displacement of the foot was inwards, as in our patient, though
produced in a very different way.t The treatment also was the same; and
the wound, which was large, became a superficial sore without suppuration or
any local or constitutional disturbance.
Another of the cases was also a dislocation inwards, caused by a lady being
thrown out of a dog-cart. She was not under my care, but I was in so far con-
cerned in the treatment that the son of her medical attendant (Dr. Coats, of
Glasgow) being at that time one of my dressers, he was asked by his father to
employ the means which he had seen me use at the hospital. In accordance
with my practice at that time, an oily solution of carbolic acid was introduced
into the joint and into the rest of the wound, and a layer of putty, rendered
antiseptic by the admixture of a certain proportion of the acid, was used for
the external dressing. The means were different, but their object was the
same. The oily solution destroyed organisms existing in the wound; and
the putty, like the lac-plaster, impermeable to watery fluid, communicated the
volatile antiseptic stored up in its substance to the discharge that flowed out
beneath it. The case was published by Dr. Coats,? who told how, after the
first smarting caused by the acid had subsided, the patient was free from the
pain previously experienced, and never after had any uneasiness in the part.
Here also the wound closed without any deep-seated suppuration or any febrile
disturbance.
In a third case, a gentleman about sixty years of age, of heavy frame,
slipped in going downstairs, and the foot was driven forcibly outwards, the
fibula being broken, while the internal malleolus was thrust through the integu-
ment. I saw the patient in conjunction with Dr. George Buchanan, of Glasgow ;
and Mr. Berkeley Hill, of London, happening to be on a visit to me at the time,
witnessed the first dressing. The lac-plaster was used, but in a way which
I have since abandoned, so that I need not trouble you with its details. After
the joint had been injected with watery solution of carbolic acid, and the dis-
location reduced, a bit of thin block-tin was placed over the wound to protect
it from the stimulating action of the acid in the plaster wrapped round the foot.
This was surrounded with a cloth and bandage, which were afterwards daily
touched with a strong solution of carbolic acid in oil, to renew a supply of the
antiseptic to the lac beneath, which was permanently retained. The tin has
* See p. 127 of this volume, * See Lancet, May 2, 1868.
142 CASE OF COMPOUND DISLOCATION OF THE ANKLE
since been superseded ; and I have found it, on the whole, better to change
the entire dressings occasionally, in the manner to be described in the sequel.]
Though the patient was of gouty habit, and in other ways by no means a very
favourable subject, his progress was all that could have been desired had the
case been one of simple fracture. [Not one drop of pus appeared till, five weeks
having elapsed, and a little serous discharge still continuing, the deeper dress-
ings were removed for the first time, and disclosed a superficial sore with pouting
granulations, which healed in a few days under an astringent lotion. ]
The fourth case was one in which the injury was inflicted by myself, but
was of the same essential nature as those caused accidentally, though its effect
was to remedy, not to produce, displacement. The foot had been driven back-
wards and outwards by the violence which occasioned a simple fracture of the
fibula and internal malleolus four months before ; and the faulty position having
continued during the union of the fragments, the limb was perfectly useless,
and the patient, a young man of twenty-nine, had the prospect of going on
crutches for the rest of his life. Relying on our antiseptic means, I did not
scruple to divide with pliers the callus of both tibia and fibula, though I knew
that in so doing I was opening into the ankle-joint. For the case differed in
this important particular from those which result from accident, that I could
guard with certainty against the introduction of putrefactive mischief while
making the wounds; whereas in the accidental cases we cannot help feeling
a degree of uncertainty till the first few days are over, whether the organisms
introduced before we see the patient have been all destroyed, though in truth
the method by injection and manipulation which I have described seems to
have reduced this to something very nearly approaching certainty. The foot
having been drawn forcibly into its proper position by means of pulleys, and
retained by appropriate splints, while an external antiseptic dressing was em-
ployed on the same principle as the putty and lac-plaster, though of different
materials, the wounds became superficial without suppuration and without the
slightest inflammation or fever ;+ and I have the satisfaction of knowing that
he, like the other patients, has now a sound and useful foot.
You see, then, Gentlemen, that I had reason for the confidence with which
I expressed myself.
In a Lecture on the 17th of February the following remarks were made :—
The case of complicated injury which we were considering three days since
goes on in accordance with our anticipations ; and I wish now to say something
regarding its subsequent management and progress.
* For further details of this case, see p. 72 of this volume.
see nce
x.
ILLUSTRATING THE ANTISEPTIC SYSTEM OF TREATMENT 143
The dressings were changed entirely on the day after the accident. [In
doing this the greatest care is requisite. For the antiseptic injected into the
wound on the previous day having been absorbed into the circulation, the
extravasated blood, and any portions of tissue killed by the violence of the
injury, are as susceptible of putrefaction as if no such treatment had been pur-
sued ; and my experience leads me to believe that if, when the dressings are
removed, a single drop of serum were to be pressed out by the movements of
the limb and then regurgitate into the interior, after being exposed even for
a second to the influence of septic air, putrefaction would be pretty certain to
occur. The skill required to guard against this risk during the first few days,
before the wound has consolidated, used to be a serious drawback to the treat-
ment. But the difficulty and uncertainty arising from this cause have been
changed to facility and security by a most simple means—the employment of
a syringe, the nozzle of which is inserted beneath the margin of the lac-plaster,
and, as this is raised, a stream of weak watery solution of carbolic acid (1 to 40)
is made to play upon the wound till a piece of calico, soaked with the same
lotion, has been placed upon it by an assistant, as a temporary security until
the plaster is reapplied. Any examination of the wound that may be desired
is made with freedom through the transparent solution thrown over it by the
syringe, the wound being never left for an instant without an antiseptic guard.
The cloths outside the lac-plaster adhere to its edges through drying of the
discharges which they absorb, and care must be taken in removing them to
hold the plaster down over the region of the wound, so that it may not be, even
for a moment, dragged up along with them. These details, while essential to
success, are, happily, easy of execution. ]
The dressing on the day after the accident and subsequently has differed
from that used in the first instance in this respect, that, before applying the
lac-plaster, the wound itself was covered with a layer of material designed to
protect it from the stimulating and irritating influence of the carbolic acid in
the antiseptic stratum. You have often seen this ‘ protective’ in use in other
cases, but I desire now to direct your attention to it more particularly.
Of all those who use antiseptics in surgery, I suspect that I apply them
least to the surface of the wound. After the first dressing, the object which
I always aim at is to have the material in contact with the exposed tissues
approximate as closely as possible to the perfectly bland and neutral characters
of the healthy living textures. If you consider the circumstances of a simple
fracture, which you cannot too often call to mind if you wish to keep your ideas
clear and right upon this subject—if you remember how the severe contused
internal wound, with the interstices of the mangled tissues loaded with extra-
144 CASE OF COMPOUND DISLOCATION OF THE ANKLE
vasated blood, recovers quickly and surely under the protection of the unbroken
integument, it is plain that all that is required in an external wound is to guard
it against the disturbing influence of external agency. The injured tissues
do not need to be ‘stimulated’ or treated with any mysterious “ specific’ ;
ALL THAT THEY NEED IS TO BE LET ALONE. Nature will then take care of them :
those which are weakened will recover, and those which have been deprived
of vitality by the injury will serve as pabulum for their living neighbours. Now,
of all external agencies the most injurious by far is putrefaction, and this, above
all, we endeavour to exclude. But a substance employed with this object,
if sufficiently potent to destroy the life of the putrefactive organisms, cannot fail
to be abnormally stimulating to the exposed tissues ; and these must be pro-
tected from its action if the wound is to progress exactly like a subcutaneous
injury.
Our ‘ protective’, then, should be a material unstimulating in its own
substance, and impervious to carbolic acid. At the same time it must be
insoluble in the discharges, and sufficiently supple to apply itself readily to the
part. But it is by no means easy to find anything fulfilling all these conditions.
Gutta-percha or caoutchouc, which naturally suggest themselves, transmit the
acid from particle to particle of their substance with the utmost facility, and
are utterly useless for this object. A metallic plate is quite impervious to the
acid. But thin block-tin, which I once used, is too rigid, while tinfoil soon
wears into holes. I have been lately trying a microscopically thin layer of
metal, in the form in which you see it in this specimen. Cotton cloth, coated
on one side with caoutchouc, is gilded on the caoutchouc side, and then covered
with a film of india-rubber applied in solution. We have ascertained that the
gold-leaf thus enclosed between two layers of caoutchouc spread on cloth wears
thoroughly well ; and, if I can get a manufacturer to enter into the thing, I have
hopes of obtaining at last something like a perfect protective. And when this
is attained, as the lac-plaster is quite trustworthy for excluding putrefaction,
our treatment will yield to the full the beautiful results which theory indicates
as possible.
There is one more point that must be mentioned with reference to the
protective. It is essential that it should be itself antiseptic at the moment of
its application, otherwise there would be a risk of its communicating septic
particles. This object can be attained by covering it with an extremely thin
film of some material soluble in water; so that when dipped into a watery
solution of the acid it may be uniformly moistened with the antiseptic, but in
so small a quantity as will be rapidly absorbed by the wound and by the skin,
so as not to interfere to any material extent with the purely protective office of |
ILLUSTRATING THE ANTISEPTIC SYSTEM OF TREATMENT 145
the application. You will bear in mind that the protective is not designed
to have any persistent antiseptic virtue; and that, like the wound at
the first dressing, it must be freely overlapped at every point by the antiseptic
plaster.
These principles will be found to apply whatever be the materials used
for carrying out the antiseptic system. An antiseptic to exclude putrefaction,
with a protective to exclude the antiseptic, will by their joint action keep the wound
free from abnormal stimulus.
Though we have not yet got a perfect protective, that which we are now
generally using answers very fairly, and has this advantage—that the materials
for it can be obtained from any druggist’s shop. The basis of it is the common
oiled silk. I am indebted to my late house surgeon, Dr. Joseph Coats, now
Pathologist to the Glasgow Royal Infirmary, for calling my attention to the
fact that carbolic acid does not pass nearly so readily through oiled silk as through
gutta-percha. But if oiled silk is dipped into a carbolic lotion before applying
it, the watery fluid runs from the surface as from a duck’s back, and there is
risk of septic particles being depositied upon the dry parts, even during the
rapid transfer from the vessel containing the lotion to the wound. I had reason
to suspect that, in some cases of hollow wounds, putrefaction was actually
brought about from this cause ; and hence I was induced to abandon the oiled
silk for a while. But of late I have had it coated with a soluble film, which
entirely removes this objection. The oiled silk is brushed over with a mixture
of one part of dextrine, two parts of powdered starch, and sixteen parts of
cold watery solution of carbolic acid (1 to 20). The carbolic-acid solution is
used rather than water, not for its antiseptic property, but because it makes
the dextrine apply itself more readily to the oiled silk, and the granular starch
is used for a similar purpose. The carbolic acid may be afterwards allowed to
fly off without disadvantage ; so that there is no need for keeping the pro-
tective, like the antiseptic plaster, in a close vessel. Oiled silk thus prepared
becomes uniformly moistened when dipped in a watery solution of the acid, so
that all risk of communicating putrefactive mischief along with it is avoided ;
and if it be used in two layers it opposes a pretty effectual barrier to carbolic
acid, as is sufficiently illustrated by the progress of the present case.
On the day after the accident the cloths around the lac-plaster applied to
the ankle, and even the pasteboard splint and its padding, were found soaked
with bloody discharge. On the second day, when the dressings were again
changed, the cloths presented only a stain corresponding to a few drachms of
tinged serum ; so that I thought it safe to allow two days to pass before the
next dressing. I believe it to be best in all cases to change everything on the
146 CASE OF) COMPOUND DISEOCGATION (OF (THETANKWE
day following the injury; because the effusion from the wound is then of a
bloody character, and though the lac-plaster certainly sheds the discharge
admirably, yet it is possible that a layer of clot may be lying beneath it, which
might interfere with its antiseptic operation. But after the first day, sangui-
neous effusion having ceased, the interval between the times of dressing should
be regulated by the amount of discharge to be anticipated ; for the more copious
it is, the sooner does it exhaust the carbolic acid in the plaster. The lac may
happily be always trusted to retain enough of the acid for twenty-four hours,
however free the discharge may be. If the stain on the cloths indicates an
effusion of only a few drachms, the plaster may be safely left for two days.
If the serous oozing be not more than a few minims, the interval may be extended
in proportion to the smallness of the amount, till finally, when, as sometimes
happens, the plaster is maintained as a precautionary measure though no
discharge is present, it may be left for a week without losing its antiseptic virtue.
When the interval between the dressings is thus prolonged, the pains taken
during the first few days are rewarded by great saving of trouble, as well as
by the satisfactory progress of the patient ; and when the case is one of fracture,
the avoidance of frequent disturbance of the limb is of course a matter of most
material consequence.
At the next dressing, four days afte: the accident, the ankle presented an
appearance which would have been impossible without antiseptic management.
The hollow wound, about three inches long, and gaping about an inch, was
still occupied by the original coagulum on a level with the surrounding skin ;
while the discharge of the last two days had caused only a serous stain of a few
minims on the cloths. But this state of things was not merely the result of
antiseptic treatment. It implied that our protective, also, was answering its
purpose well. Had the antiseptic been acting directly on the wound, the dis-
charge would have been much more considerable, and we should probably
have already had a hollow sore with commencing suppuration. Here I cannot
help observing that it seems to me strange that some who have not scrupled to
criticize me with great severity should have taken so little trouble to ascertain
what I have written on this subject. From the remarks made by some persons,
you would imagine that I regard putrefaction as the sole cause of suppuration ;
whereas my treatment of abscess depends essentially upon the fact that the
pus in the unopened cavity, being the result of the inflammatory stimulus
without atmospheric influence, is free from putrefaction, so that it is needless to
apply the antiseptic to the interior, all that is requisite being to provide exit
for the discharge while guarding against the entrance of putrefactive fermenta-
tion. Again, from the statements of others you would suppose me to have
ILLUSTRATING THE ANTISEPTIC SYSTEM OF TREATMENT 147
taught that, if you do but apply carbolic acid freely to a wound, you will prevent
suppuration ; whereas I have all along pointed out that carbolic acid, being
a stimulating substance, will itself induce suppuration by long-continued action
on the tissues.?
[The facts observed in developing the antiseptic system have thrown great
light upon the causes which determine the occurrence of suppuration ; and
the subject is of such great practical importance that it may be well to take
this opportunity of giving definite expression to the conclusions to which I have
been led. It fell to my lot several years ago to establish, as the result of an
experimental inquiry, that the tissues of the living body are liable to a temporary
impairment or suspension of vital energy as the result of extreme irritation ;
and that this condition, which appears to be the essence of imtense inflammation,
may be brought about in two totally distinct ways—viz. either by the direct
operation of a noxious agent upon the tissues, or indirectly through the medium
of the nervous system.” The same law appears to hold with regard to the causes
of the exaggerated but feeble cell-development which results from the continued
action on the tissues of some abnormal stimulus in a less intense form, giving
rise, according to its degree, to the various phenomena of inflammatory hyper-
trophy, granulation, and suppuration; the pus-cells being the extreme of
excess of quantity and impairment of quality in the product of abnormally
excited nutrition. Thus the causes of suppuration divide themselves into two
great groups: first, those that operate through the nervous system, or, in other
words, the inflammatory class, of which the common abscess presents a typical
example ; and, secondly, noxious agents or stimuli acting directly on the tissues.
The latter group are, practically speaking, stimulating salts, or chemical stimuli.
These are best studied in the behaviour of a healing ulcer under different
kinds of treatment. Small granulating sores sometimes heal by scabbing ; and
when the surface is thus protected by a crust of dried discharge from the in-
fluence of external agency, there is no further effusion either of pus or serum.
This is of itself sufficient evidence that granulations have no inherent tendency
to form pus (or, as is sometimes absurdly said, to secrete it), but only do so
when stimulated. The same thing is equally clearly shown by the well-known
fact that two granulating surfaces will coalesce when placed in contact with
each other. This coalescence would be impossible if they continued to sup-
purate ; and their juxtaposition could oppose no obstacle to pus-formation if
they had any innate disposition to it. But their mutual contact excludes the
operation of external agents upon them; being freed from stimulation, they
* See pp. 6, 78 of this volume.
* “On the Early Stages of Inflammation.’—Phil. Trans., 1858 (reprinted in vol. 1, p. 209).
148 CASE OF ‘COMPOUND (DISLOCATION (OF THE ANI:
cease to discharge; and they are then at liberty to coalesce. New examples
of the same truth present themselves under the antiseptic system of treatment.
The wall of an abscess is similar in nature to the granulations of a sore, and is
often regarded as essentially ‘pyogenic’. But if the abscess is opened anti-
septically, the pyogenic membrane, being relieved from the inflammatory
stimulus which the tension of the pus before induced, and being at the same
time protected from the access of the stimulus of putrefaction, is left free from
all disturbance, and never forms another drop of pus. But the most striking
illustration I ever saw of the properties of granulations, when not subjected to
stimulation, was presented by a case of compound fracture, in which an
extensive portion of the shaft of the tibia had lost its vitality, and lay
exposed in a large granulating sore. The granulations grew up and enclosed
the dead bone, which, being prevented from putrefaction by the treatment
employed, was destitute of the usual acrid properties of an exfoliation ; so
that the granulations, being not stimulated by it, not only formed no pus from
the surface in contact with it, but gradually consumed the dead mass by
absorption.1
The truth is, that so far from granulations having any inherent tendency
to form pus-corpuscles, the imperfect tissue of which they consist is ever disposed
to develop into higher forms as soon as it is left free from preternatural excite-
ment. This is beautifully illustrated by the familiar phenomena of the healing
ulcer. The granulations are still granulations—that is to say, possess still the
same pathological structure, when covered by the pellicle of newly formed
epidermis at the edge of the sore, as when they were exposed. But no sooner
does the film of young epithelium protect the imperfect tissue from the influence
of external stimulus than the rudimentary structure of the granulations im-
mediately proceeds to develop into the more and more perfect fibrous tissue
of the cicatrix.
It being, then, clearly understood that granulations form pus only when
abnormally stimulated, we are in a position to estimate the effects of different
agents upon them. The simplest case is when an antiseptic substance, like
chloride of zinc or carbolic acid, is applied, suitably diluted, to a healthy granu-
lating sore. Not the slightest redness of the surrounding skin, or any other
indication of inflammatory disturbance, is produced; yet the granulations, so
far as they are exposed to the influence of the stimulating liquid, are excited to
superficial suppuration, but form no pus where they are protected from the
stimulus by the pellicle of epidermis at the margin. Here, then, we have entire
absence of the inflammatory stimulus ; but the chemical stimulus of the pungent
1 See p. 16 of this volume.
ILLUSTRATING THE ANTISEPTIC SYSTEM OF TREATMENT 149
antiseptic salt urges the superficial cells of the granulations to develop pus-
corpuscles.
If the sore is treated with water dressing, the serum first exuded putrefies
in the lint, and the products of putrefaction, being acrid salts, cannot fail to
stimulate the surface of the granulations ; and accordingly superficial suppura-
tion is induced without any appearance of inflammation, just as under the
influence of the antiseptic. Thus, in their effects upon a granulating sore, an
antiseptic and a putrid dressing are alike: both excite superficial suppuration
by direct chemical stimulation of the granulations. But in their operation on
a recent wound there jis this all-important difference between them, that the
antiseptic stimulates only the surface to which it is applied, and every drop
of discharge which it induces dilutes it and renders it less stimulating ; but
putrefaction being a fermentation, the self-propagating ferment spreads through-
out all the recesses of the wound, wherever extravasated blood, or serum, or
portions of dead tissue afford nidus and pabulum for its development, and its
products become more and more acrid the longer it continues in operation.
Antiseptics, then, though they do produce suppuration when applied con-
tinuously to a recent wound, are superficial in their action and utterly trivial
compared with the deep and virulent effects of putrefaction, which, indeed,
often causes death by irritation and blood-poisoning before suppuration has
had time to be established.
These conclusions may be exhibited in a diagrammatic form as follows :—
Causes of Suppuration.
Abnormal ‘- Through excited nervous )
stimulation | a | action )
of the ; , From the direct action of )
tissues, | | stimulating salts
Inflammatory.
a. Putrefactive.
B b. Antiseptic.
This scheme, though not strictly exhaustive, applies to almost all circum-
stances met with in surgery ; and it will be found to conduce to clearness to
speak of suppuration as inflammatory, putrefactive, or antiseptic, according to
the circumstances in which it occurs.®]
If the use of the protective be so advantageous, you may naturally inquire
why I do not employ it at the first dressing. The reason is twofold. In the
* The group a ought to include the products of other ferments besides those of putrefaction. For
I am satisfied that inodorous ferments sometimes occur in the animal fluids, and produce salts which
stimulate to suppuration. Also viruses inducing suppuration are very probably of the same essential
nature (ferments), though some at least are odourless, as in the case of erysipelas. Again, the group 8,
to be complete, should include salts which, though not the products of putrefaction, cannot be said
to be antiseptic, such as dilute chloride of sodium, &c.
* Any special case, not falling under the scheme, may be called according to its special nature ;
thus we may speak of erysipelatous suppuration, variolous suppuration, &c.
150 CASE OF COMPOUND DISLOCATION OF THE ANKLE
first place, there must necessarily be a considerable discharge of blood and
serum during the first twenty-four hours, and hence this is the period in which
there is greatest risk of putrefaction spreading into the wound, so that it does
not seem wise to interpose anything that can interfere in the slightest degree
with the antiseptic action of the dressing. And, in the second place, there is
no chance of a suppurating sore being established by the direct action of the
antiseptic upon the wound for a single day only. This leads me to speak: of
a condition of suppuration to which I have not before had occasion to advert—
viz. the element of time. When the tissues are in a healthy state, no stimulus
can induce them to suppurate. It appears that it is only when the tissues have
been gradually degraded, under the influence of protracted abnormal stimula-
tion, into the most imperfect of all tissues, which, when we see it at the surface
of a sore, we term granulations, that they are in a condition, if further stimulated,
to give birth to the still lower progeny of pus-corpuscles. In other words,
granulation must precede suppuration, and it is a process which requires days
for its completion.’ Thus it is a familiar fact to all surgeons that a recent wound
in healthy tissues does not suppurate for three or four days when subjected to
ordinary treatment—that is to say, the stimulus of putrefying material must act
for three or four days upon the tissues before it can induce them to suppurate ;
and when the first-formed pus is wiped from the wound, granulations may be
seen upon the surface.
The same holds with regard to the inflammatory stimulus. Inflammation
does not produce suppuration in a day. Whether acute or chronic, it must
first degrade the tissues to granulations before it can occasion the formation of
pus. This is well illustrated by a common boil, which is a limited inflammation
of the cutis vera, so severe at the centre as to destroy the vitality of a portion
of the tissue, and gradually shading off to the state of health in the vicinity.
Here, though all possible degrees of intensity of inflammation are present,
between the centre and the circumference, no pus is produced till some days
have elapsed. Then the ‘ core separates’, as it is said, and the slough is found
detached from the neighbouring living tissues, and surrounded by a few drops
of odourless pus. But when the slough and the pus are removed, the cavity
in which they lay is seen to be lined with granulations. The inflammatory
stimulus, like the putrefactive, had induced granulation as a preliminary to
suppuration.
* An exception to this statement must be made for the case of the epithelium of some mucous mem-
branes, the cells of which, originally of simple structure, soon form pus-corpuscles under slight abnormal
stimulation. While thus adopting the language of the ‘ Cellular Pathology’, elaborated by Virchow
and others following the path first opened up by Goodsir, I may remark that my own experience has
tended to convince me of the truth of that doctrine.
ILLUSTRATING THE ANTISEPTIC SYSTEM OF TREATMENT 152
In the same way, an antiseptic must act for days upon a wound before it
can convert it into a granulating sore liable to suppuration ; so that no harm
is done by omitting the protective for the first twenty-four hours.
The other injuries in our patient have thus far proceeded as satisfactorily
as that of the ankle. The four severe scalp-wounds were dressed on the day
after the accident, and each was covered with protective before the cap of lac-
plaster was reapplied. On the following day, the discharge to be seen on the
cloth round the lac was so slight that I thought it safe to leave the head undis-
turbed for another day. The second dressing was witnessed by some of you
just after last lecture. The discharge of the two days amounted to only a few
minims of serum, and there was entire absence of redness, puffiness, or tender-
ness of the scalp. I removed the numerous sutures, each coming out as clean
as when it was introduced; and all the wounds seemed already completely
healed, except a small superficial raw surface here and there.
The compound fracture into the elbow-joint, when last dressed, presented
only a trace of serous discharge, so that I shall not think it needful to disturb
it till five days shall have passed since that occasion.
The following remarks conclude the case :—
Before proceeding to relate the further progress of this case, I have to
direct attention to another circumstance of great practical importance in the
injury to the ankle. On the day after the accident it became apparent that
the violence to which the part had been subjected had destroyed the vitality
of portions of the integument, not only at the anterior margin of the wound,
where a slough about half an inch in breadth existed, but also in detached
patches at the outer aspect of the dorsum of the foot. Now, if any one of these
dead pieces of skin had been left exposed to atmospheric influence, it would
have putrefied; and the putrefaction would in all probability have spread
along the extravasated blood and serum in the subcutaneous tissue till it had
reached the seat of fracture and the articulation, and all our antiseptic treatment
of the wound would have proved nugatory. I once saw a case of compound
fracture of the forearm, in which the antiseptic treatment had been pursued
with thoroughly efficient means, but after the lapse of some days I was asked
to look at the limb, in consequence of unsatisfactory appearances. I found the
dressings applied perfectly correctly, and I had no reason to doubt that they
had been so from the first ; but the wound, when exposed, emitted an offensive
discharge. On investigation I found a small slough of the skin, about half an
inch in diameter, situated some inches from the wound, and just beyond the
limits to which the lac-plaster had been extended. The little slough had by
152 CASE OF COMPOUND: DISLOCATION OF THE ANKLE
this time undergone softening from putrefaction, so that the nozzle of a syringe
could be introduced through it ; and, on injecting some of the watery solution
of carbolic acid, I found that it passed freely beneath the integument to the
seat of fracture and to the external wound. Whether the skin had been thus
extensively detached at the time of the accident, or whether the subcutaneous
tissue had been simply loaded with extravasated blood, the spreading of the
putrefactive fermentation from the slough exposed to the air was easily
intelligible.
It is therefore essential that every isolated slough which may exist in the
vicinity of a contused wound should be dressed antiseptically like the wound
itself. But it may be asked, How is it possible to secure this at the time of
the first dressing, seeing that there is nothing in the appearance of the skin
in the first instance to indicate that vitality has been destroyed? The simple
rule for attaining the desired object is to let the antiseptic plaster first applied
overlap the apparently uninjured skin far and wide in all directions. Then,
on the following day, let the integument be carefully scrutinized, when any
dead portions will be recognized by a dusky discoloration. Every such dis-
coloured patch should then be dressed, as if it were a wound, with a piece of
protective and well-overlapping lac-plaster. If the protective were omitted,
the slough would acquire stimulating properties from the carbolic acid per-
petually communicated to it by the lac-plaster, and would excite the neighbouring
living parts to granulation and ‘antiseptic suppuration’. But if efficiently
protected from the antiseptic, as well as from putrefaction, the dead tissues
will be absorbed and organized like the clots of blood, new living structures
being formed at the expense of the effete but nutritious mass.
Such was the course pursued in the present case ; and, the oiled silk protec-
tive having been used in two, and sometimes three, layers, the results have
approached very closely to those which are theoretically attainable. Some of the
smaller portions of slough have been entirely removed by absorption, their
place being taken by vascular new tissue. Five weeks after the accident, the
large slough at the anterior margin of the wound had been considerably reduced
in superficial extent, without the formation of any line of separation. What
remained of it was of firm consistence, though of yellowish-white colour. In
order to ascertain to what extent the process of organization and vascularization
had advanced in it, I scratched its central part with the point of a sharp knife,
and found that the little incision bled when I reached a depth not above half
that of the cutis vera, whereas the original slough had undoubtedly involved,
not only the entire cutis, but the subcutaneous fat. The mass of dead tissue,
though superficially situated, being protected from the disturbing influence
ILLUSTRATING THE. ANTISEPTIC SYSTEM OF TREATMENT 153
of external agency, was undergoing the same kind of change as is experienced
by parts deprived of vitality in the subcutaneous injury of a simple fracture.
The appearances of the wound itself presented an equally striking difference
from those met with under ordinary treatment. Even at that late period, five
weeks after the accident, the original clot was still to be seen, of an orange-
brown colour, on a level with the surrounding skin, but greatly diminished by
contraction and also by cicatrization, epidermic formation having advanced
considerably from all parts of the margin of the wound, except anteriorly,
where the slough was present. An open sore healing by cicatrization without
suppuration, or even granulation, is something new in the history of surgery,
though exactly what might have been expected from what we know of healing
by scabbing. At the lower extremity of the wound the new and vascular tissue
which had been formed by organization of the clot was shghtly more prominent
than the rest, and had somewhat the characters of granulations covered with
epidermis. But not a trace of pus had been produced. On the occasion when
these observations were made, eight days had been allowed to pass since the
last dressing, and in order to estimate accurately the quantity and quality of
the discharge, I removed the lac-plaster without injecting any watery solution
beneath it, knowing that at this late period no risk would be incurred by free
exposure of the wound. The bandage outside the plaster being free from stain,
the whole discharge of eight days had accumulated beneath the impermeable
layer of lac, and consisted only of about two minims of white but thin fluid,
together with some desquamated epidermis. I subjected the milky liquid to
microscopic examination, and found that the opaque element was composed
exclusively of epidermic scales.
The vascularization of the clot, like that of the sloughs, had been advancing
from below as well as round the margins. Fifteen days after the accident
I cut into the central part of the then chocolate-coloured coagulum, under the
protection of a stream of watery solution of carbolic acid, and found that it
did not bleed, though the knife penetrated about a quarter of an inch. But
on a repetition of the experiment twelve days later, blood oozed up from an
incision carried to only about the depth of an eighth of an inch.
The process of organization of clots and sloughs thus observed in an external
wound, though of the same essential nature as that which occurs in subcutaneous
injuries, was undoubtedly retarded by a certain degree of abnormal stimulation
inseparable from the method of treatment. For, besides the fact that the
protective was not perfect—i.e. not absolutely impermeable to the carbolic acid
furnished by the lac-plaster—the clot and sloughs were more or less soaked with
the antiseptic lotion every time the dressings were changed; and though the
LISTER II M
154 CASE OF COMPOUND DISLOCATION OF THE ANKLE
acid is soon diffused and carried away by the circulation, this circumstance
necessarily operated as a disturbing cause. Hence the rate of healing will be
more rapid in proportion to the efficiency of the protective, and also to the
length of the intervals that can be allowed to pass between the dressings con-
sistently with security against putrefaction. In the present case, the period
between the dressings was extended as the discharge diminished, and it may
be worth while to mention the successive intervals. From the date of the
accident they were as follows: one day; one day; two days; three days ;
three days ; five days ; five days ; seven days ; and finally eight days ; bringing
the time up to five weeks from the receipt of the injury. But I am not prepared
to recommend a longer time than a week, and even that only when the discharge
is practically mid. Indeed, in our patient, putrefaction did take place in the
period following that of eight days. I had intended allowing another week to
pass before meddling with the limb, but at the close of the sixth day my house
surgeon informed me that the patient had got up two days before, without
leave, and had made his way, on chairs as crutches, to the fire, a distance of
several yards ; and, further, that there was an appearance of a stain upon the
bandage. I therefore exposed the limb, and found that the discharge was
considerably greater (amounting to perhaps half a drachm), fetid, and, for the
first time since the accident, unmistakably puriform. The dressings removed
on the last occasion had been perfectly odourless; and the most probable
explanation seemed to be, that the vascular engorgement of the limb occasioned
by the dependent posture had induced an unusual exudation of serum from
the wound, and that this circumstance, combined perhaps with some movements
of the foot, had proved too much for the antiseptic power of the lac-plaster at
that period after its application. Happily the occurrence was of no consequence,
as the wound was practically superficial, and beyond the reach of danger from
putrefaction. But it may serve as a warning. And it must ever be borne in
mind that, in the earlier stages of such a case as this, where the avoidance of
putrefaction may be a matter of life and death, it is better to err on the side of
dressing too often, rather than too seldom.
The putrefaction had evidently occurred quite recently, for the clot and
sloughs were not yet detached. I clipped away most of the slough, and scraped
off the clot till I got down to bleeding tissue, and, with the view of correcting
the putrefaction in such portions of dead material as remained, I treated the
sore with a strong solution of carbolic acid in spirit of wine (one part to five),
and, having washed the skin around with watery solution, applied lac-plaster,
omitting the protective. Next day, however, the putrefaction was reproduced ;
showing that the antiseptic employed had not thoroughly penetrated the adher-
ILLUSTRATING THE ANTISEPTIC SYSTEM OF TREATMENT © 155
ing portions of slough. Having at hand some saturated solution of chlorine gas
in water (the liquor chlori of the British Pharmacopoeia), I applied it freely
to the sore and also to the surrounding integument, and then dressed with
protective dipped in chlorine water and covered with overlapping lac, as formerly.
On the following day the sore was destitute of odour of any kind, while the
discharge was greatly reduced. For the future it will be treated as a superficial
ulcer.
With regard to the injury to the ankle, it only remains to be mentioned
that, at the present time, six weeks after the accident, the fracture of the internal
malleolus has united firmly, and the foot is in good position ; while the patient
has already considerable movement of the ankle-joint.
The four severe scalp-wounds—three of which, it will be remembered,
involved exposure and injury of the bone—healed completely, without the
formation of a drop of pus. And it was an interesting circumstance that, on
the removal of some scabs, one of the silk sutures, which had been accidentally
left, was found still securely in its place, three weeks after its introduction, and
came away clean and dry, like a metallic stitch.
The compound fracture into the elbow-joint also healed without any sup-
puration. Five weeks after the receipt of the injury the splint was removed.
The broken olecranon was found firmly united, and the patient has now free
motion of the articulation.
Edinburgh, March 26, 1870.
M 2
FURTHER EVIDENCE REGARDING THE EFFECTS OF
THE ANTISEPTIC SYSTEM OF TREATMENT UPON
THE: SALUBRITVY OF VA SURGICAL HOsPrtat&
[Lancet, 1870, vol. ii, p. 287.]
IN the early part of this year a paper was published in the Lancet,’ in which
I recorded the general results of my practice in the Glasgow Infirmary during
three years in which the antiseptic system of treatment had been carried out,
as compared with my previous experience in the same institution with ordinary
management of the cases. It was there shown that the strict enforcement of
the antiseptic principle had been accompanied by a most striking change in
the salubrity of the wards under my care, which had been converted from
some of the most unhealthy in the kingdom into models of healthiness; and
I ventured, in conclusion, to make the following remark: ‘Considering the
circumstances of those wards, it seems hardly too much to expect that the same
beneficent change which passed over them will take place in all surgical hospitals
when the principle shall be similarly recognized and acted on by the profession
generally.’ I have now the pleasure of announcing an instance of the fulfil-
ment of this anticipation, as related in the following letter from Dr. Saxtorph,
Professor of Clinical Surgery in the University of Copenhagen.
“My dear Sir.—It is now nearly a year since I left Glasgow, where I had
the opportunity of seeing how the antiseptic treatment of wounds is to be carried
out. Every surgeon who has seen the remarkable results of this treatment
must feel it his duty to imitate you, and dress the wounds after your principles.
I therefore, as soon as I came home, adopted your method, and have used it
now continually since that time ; and I am happy to say that, although I have
not generally succeeded in obtaining complete primary union, except in smaller
wounds, still the treatment has proved in other respects extremely satisfactory.
The hospital to which I am appointed head surgeon (the Frederik’s Hospital)
is a very old building—in fact, it is now much more than a hundred years old—
and it contains about 350 medical and surgical beds. In the surgical wards
I have room for about 150 patients ; but the usual number during the winter
has varied from 100 to 130. Formerly there used to be every year several
cases of death caused by hospital diseases, especially by pyaemia ; sometimes
arising from the most trivial injuries. Now, I have had the satisfaction that
not a single case of pyaemia has occurred since I came home last year, which
result is certainly owing to the introduction of your antiseptic treatment. But
+ See p. 123 of this volume.
FURTHER EVIDENCE ON ANTISEPTIC SYSTEM OF TREATMENT 157
it must be clear to any surgeon who has adopted your method that unless you
take the greatest precautions in every dressing till the wound is either healed
or filled up with granulations, you will never see the excellent effects of this
treatment. It certainly takes much longer time, and demands much greater
precautions, than any other dressing ; but the reward is certain, and it is a great
satisfaction to know that the good result of many operations almost entirely
depends upon your dressing of the wound. As an instance of this I may men-
tion the following case: A man came to me with a foreign body in the left
knee. I thought it to be, not a loose cartilage, but a fragment of the tibia,
loosened by the kick of a horse eight years ago. It was situated behind the
ligamentum patellae, was a little movable, and grated very distinctly as two
osseous surfaces would do. I made a large incision on the outer side of the
capsule and tried to extract it, but the surfaces were so much entangled in each
other that I was obliged to use my finger and different hooks and forceps before
I got it out. The operation lasted certainly a quarter of an hour, and during
the whole time I poured a stream of carbolic solution over the wound. Having
extracted it at last, it proved to be really a part of the head of the tibia with
its cartilaginous surface on it, and of the size of a small walnut. I treated anti-
septically, and the wound closed without any suppuration in the joint. All the
compound fractures which I had to deal with last year, some of them very
severe ones, have healed without the least suppuration in the fracture itself,
and the consolidation did not take much longer time than in a simple fracture.
All the amputations of this year have recovered. There has certainly been some
suppuration, but it never became profuse, and I never observed any putrefaction.
I feel so much indebted to you for what I have learnt in seeing you employing the
antiseptic dressing, that I thought it my duty to let you know how things went
on in my hospital practice ; and I am happy to say that I never tried any inno-
vation which answered so admirably as this treatment of wounds.—Believe me,
my dear Sir, ever yours,
‘ SAXTORPH.
‘July 18, 1870.
It may seem strange that results like these should have been obtained in
Copenhagen, when so little approach to them has yet been made in the capital
of England. The fact, however, is not difficult to explain. Want of success
in many quarters has not arisen from any unwillingness to try a new mode of
practice. On the contrary, the publication of my first papers was followed
by a very general employment of the material which I happened to select for
carrying out the treatment, and which, unfortunately for the principle involved,
was then little known in British surgery, so that the striking results which were
recorded were too often attributed to some specific virtue in the agent. The
antiseptic system does not owe its efficacy to any such cause, nor can it be
taught by any rule of thumb. One rule, indeed, there is of universal applica-
tion—namely this: whatever be the antiseptic means employed (and they may
be very various), use them so as to render impossible the existence of a living septic
organism in the part concerned. But the carrying out of this rule implies a con-
158 FURTHER EVIDENCE ON ANTISEPTIC SYSTEM OF TREATMENT
viction of the truth of the germ theory of putrefaction, which, unfortunately,
is in this country the subject of doubts such as I confess surprise me, considering
the character of the evidence which has been adduced in support of it. Yet,
without this guiding principle, many parts of the treatment would be unmeaning ;
and the surgeon, even if he should attempt the servile imitation of a practice
which he did not understand, would be constantly lable to deviate from the
proper course in some apparently trivial but essential detail, and then, ignorant
of his own mistake, would attribute the bad result to imperfection of the method.
For my own part, I find that, in order to approach more and more to uniform
success, it is necessary to act ever more strictly in accordance with the dictates
of the germ theory. Failure on the part of those who doubt or disbelieve it is
therefore only what I should expect.
Another great cause of failure undoubtedly is, the careful attention necessary
in order to exclude, from first to last, the subtle putrefactive organisms that
people the atmosphere and form part of the dust which adheres to all exposed
objects. The germ theory, while it furnishes the clue to success, affords ample
explanation of failure. I believe I do my professional brethren in Britain no
more than justice when I say that if they felt anything like the assurance
expressed in Professor Saxtorph’s words, ‘the reward is certain,’ they would
not grudge a greater degree of trouble than the antiseptic treatment demands.
And, in truth, when once a surgeon has become thoroughly initiated into the
practice, it is in most cases a saving of trouble. Thus I have at present a patient
about to leave the infirmary three weeks after the removal of the entire mamma
for scirrhus, all the axillary glands having been at the same time cleared out
after division of both the pectoral muscles, so as to permit the shoulder to be
thrown back and the axilla freely exposed, as is done in the dissecting-room—
a practice which I have for some years adopted where the lymphatic glands
are affected in that disease. In this case a great deal of care was certainly
required for the first few days ; but after a week the dressings were only changed
once in three days, and when a fortnight had elapsed, cicatrization being almost
perfect, a week was allowed to pass without any interference. Hence, on the
whole, the labour was considerably less than with ordinary treatment, and
a very much greater amount of pains would have been amply repaid by the
beautiful linear cicatrix, formed without the occurrence of one drop of pus,
and without any serious constitutional disturbance. This, however, was an
instance in which an unusual degree of care was requisite ; for the axilla is one
of the most difficult situations in the body to guard antiseptically, and I have
only myself learnt quite recently the art of doing this, as I believe, with security.
But in most cases the details of the treatment are not troublesome to execute
AND THE SALUBRITY OF A SURGICAL HOSPITAL 159
by any one accustomed to them; yet they nevertheless require at first earnest
practical study until their employment has become habitual and instinctive.
It is therefore not to be wondered at that surgeons endeavouring to carry out
the treatment without having seen it in operation, and only half persuaded
of the importance of the object to be attained, should fail time after time, and
throw up the attempt in disgust. Professor Saxtorph, on the other hand,
having observed the effects of the antiseptic treatment, and appreciated its
importance, spent a considerable time in carefully watching it in operation,
and then set to work in right good earnest to carry it out ; and, as he believes
in the germ theory of putrefaction, it is not surprising that sound principle
and careful practice should have been crowned with the success which he has
related.
I had not intended to have published anything regarding the general con-
dition of my wards in Edinburgh till a longer period should have elapsed. But
in connexion with Professor Saxtorph’s letter, I may state that, having now
been in charge of fifty beds for nine months in the Royal Infirmary here, I have
as yet had no instance of pyaemia, although many cases have been admitted
in which it might, under ordinary treatment, have been apprehended, such as
compound fractures, amputations in the lower limb, and extensive gouging
operations upon bone. Hospital gangrene also has been entirely absent.
Though several cases of ulcers of long standing have been under treatment,
there has never been any appearance of greyness of the surface to indicate even
the mildest form of the disease.
Two cases of superficial erysipelas occurred in December ; but these seemed
to me attributable to cold rather than to any poisonous condition of the atmo-
sphere. In my former paper on this subject I mentioned a case’ in which
erysipelas appeared in a stump after amputation of a leg, long after the patient
had left the Glasgow Infirmary with the wound entirely cicatrized; and I
remarked upon the interest of that case as occupying an intermediate position
between traumatic and idiopathic erysipelas, implying that local irritation of
such trivial nature as that of a contracting cicatrix might determine the occurrence
of the complaint in a person predisposed to it constitutionally. We know also
that exposure to cold is the most common exciting cause of the idiopathic form
of the disease, which is entirely independent of any unhealthy state of the air,
It therefore seems not unreasonable to suppose that where the local irritation
of a wound coexists with a chill, traumatic erysipelatous inflammation may
become developed in some persons in a perfectly pure atmosphere ; and such
seemed the most probable explanation of the two cases to which I am now
* See p. 133 of this volume.
160 FURTHER EVIDENCE ON ANTISEPTIC SYSTEM OF TREATMENT
referring. One of them was a man above the middle period of life, in whom
I had performed amputation at the knee-joint. Five days after the operation,
the discharge amounting to only a few minims of serum in the twenty-four
hours, and the patient being free from constitutional symptoms, I thought him
a favourable subject for illustrating the antiseptic dressing of a stump before
the clinical class. Accordingly I had him taken into the theatre, and dressed
him there ; and, not thinking how time was passing, I left the stump covered
only with a piece of calico soaked with cold watery solution of carbolic acid
while I discussed at considerable length the mode of procedure. It happened
to be one of the coldest days of that severe winter, and it afterwards occurred
to me that I had been guilty of imprudence in exposing the stump so long.
Next day he complained of not feeling so well, and the skin near the wound
exhibited the commencement of an erysipelatous blush, which spread some
distance up the trunk before it finally subsided. The other case was one of
removal of the mamma for scirrhus. In changing the dressings the exposed
surface of the chest was syringed with the cold watery solution of carbolic acid,
and, in that very cold weather, a chill was certainly not unlikely to occur from
such treatment. Here also a blush of redness appeared near the wound, and,
though it was only superficial and did not spread far, it was unmistakably
erysipelatous. Taking this view of the cause of the complaint in these two
cases, I adopted the simple expedient of making the 1 to 40 watery solution
of carbolic acid by mixing that of the strength 1 to 20 with an equal quantity
of hot water, so as to make a warm lotion ; and during the seven months in which
this plan has been pursued we have had no more appearance of erysipelas.
Thus my wards, although by no means models, as regards their principle
of construction or the space allowed between the beds, appear perfectly free
from any liability to hospital diseases.
Edinburgh, July 22, 1870.
A METHOD OF ANTISEPTIC TREATMENT
APPLICABLE TO WOUNDED SOLDIERS
IN THE PRESENT WAR
[British Medical Journal, 1870, vol. li, p. 243.]
HAVING been requested to furnish some rules for the antiseptic treatment
of wounded soldiers in the present war, I venture to suggest the following plan,
in the hope that it will combine efficiency with the simplicity and facility of
execution essential under such circumstances.
Wash the wound thoroughly, and also the surrounding skin, with a saturated
solution of crystallized carbolic (phenic) acid in water, one part of the acid to
twenty of water, introducing the fluid by means of a syringe, and manipulating
‘the parts freely so as to cause the lotion to penetrate into all the interstices of
the wound; and at the same time squeeze out such clots of blood as it may
contain. The fluid should be introduced repeatedly to ensure its thorough
penetration. Tie any bleeding vessels with properly prepared antiseptic catgut,
cutting off the ends of the thread near the knot. If the surgeon do not possess
this article, the arteries should, if possible, be secured by torsion ; but for the
sake of cases in which a ligature would be absolutely indispensable, some silk
or linen thread should be kept steeping in a strong oily solution of carbolic
acid, or, if very fine silk be used, it may be rendered antiseptic by steeping for
a few minutes in the watery solution. When silk or linen is employed, the
ends of the ligatures should be left projecting at the wound. While the anti-
septic lotion is in the wound, extract if possible any foreign material that may
have been introduced, such as a bullet or a portion of the patient’s clothes ;
and if any spicula of bone exist entirely detached from the soft parts, remove
such as can be readily reached, disregarding those which are of very small size
or inconvenient of access.!. Then place upon the wound two or three layers
of oiled silk smeared on both sides with a solution of carbolic acid in five parts
of any of the fixed oils—olive, almond, linseed, &c.—the oiled silk being made
large enough to cover the raw surface completely and slightly overlap the sur-
rounding skin. Next apply, without loss of time, lint, charpie, or cloth (linen
* Gunshot-wounds should not be stitched ; but, where sutures are required, silk, steeped in oily
solution of carbolic acid, will answer sufficiently well. After the introduction of the last stitch, distend
the wound once more with the watery solution, by means of the syringe, and then continue the dressing,
as in the text.
162 A METHOD OF ANTISEPTIC TREATMENT
or cotton), well steeped in the oily solution of the acid, the cloth or lint being
folded sufficiently to produce a layer at least a quarter of an inch in thickness,
and extending a considerable distance, say three inches, beyond the oiled silk
in all directions, the outer layer being made somewhat larger than the rest, so that
the margin of the mass of cloth may be thin. Cover the oily cloth with a piece
of thin gutta-percha tissue sufficiently large to overlap it on all sides by an
inch or more, and retain it securely in position by a roller steeped in the anti-
septic oil. Round this again wrap a still larger piece of folded cloth, say a folded
towel, also steeped in the oily solution of carbolic acid, and cover it with a piece
of oiled silk or gutta-percha.
With a view to the intelligent application of this dressing, it will be well
to state briefly its vationale. The watery solution is applied in order to destroy
once for all any septic particles that may have been introduced into the
wound ; and the oily solution is employed to prevent the spread of putrefactive
fermentation into the wound from without. The oiled silk, which is but shghtly
permeable to carbolic acid, protects the raw surface from the irritation of the
acid in the oily cloth, and permits it to heal as under a scab. But though the
ultimate office of the oiled silk is to protect the wound from the irritation of
the antiseptic, it must itself be antiseptic at the time of application, and is
therefore smeared with the oil, which in the course of no long time loses its
carbolic acid by diffusion into the wound beneath. The substantial and widely
extending oily cloth serves as a store of the antiseptic; but the bloody and
serous discharge soaking into the porous cloth tends to wash away the oil and
deprive the dressing of its antiseptic character; hence the necessity for the
gutta-percha, which prevents the discharge from making its way directly out-
wards from the wound, and so establishing a road for the penetration of putre-
faction inwards. At the same time the gutta-percha, though impermeable to
watery or oily fluid, being readily permeated by carbolic acid, permits the anti-
septic ingredient to pass in through it from the outer cloth and act upon the
discharge that flows out beneath the overlapping margins of the gutta-percha.
The outer cloth is intended to be changed as occasion may require, in order to
keep up the supply of the antiseptic, while the gutta-percha and all beneath
it constitute a more permanent application. The layer of gutta-percha or
oiled silk outside the external cloth is to prevent the oil in that cloth from being
wasted by soaking out into the surrounding articles of clothing, &c.; or, still
worse, neutralized chemically by the penetration inwards of putrid blood or
other discharges from the ambulance-wagon or bedding. The circumferential
part of the deeper cloth will, in consequence of its thinness, be kept completely
antiseptic by the carbolic acid which passes inwards through the gutta-percha,
APPLICABLE TO WOUNDED SOLDIERS 163
while the deeper layers of the thicker portion over the wound will probably
in a few days be destitute of antiseptic, and therefore of stimulating, properties ;
hence the oiled silk, though desirable in order to ensure the absence of ‘ anti-
septic suppuration ’, is by no means an essential part of the treatment, and if
none of it be at hand the procedure may in other respects be conducted in the
same way without it. Again, if the surgeon have no gutta-percha at his dis-
posal, the risk that would otherwise arise from the permeability of the dressing
may be overcome by frequently changing an external antiseptic cloth, or by
treating its surface every few hours with the antiseptic oil.
The changing of the outer cloth will require care in order to avoid raising
the edge of the gutta-percha along with it, and so admitting septic air towards
the wound. It may be done with perfect security by having the cloth consist
of two parts, one covering each half of the gutta-percha, and, as one half is
raised, throwing a stream of watery solution (I to 40) with a syringe upon the
margin of the gutta-percha, a fresh oiled cloth being at once applied before the
other portion of the former cloth is removed. If sufficient time cannot be spared
for changing the outer cloth in this careful manner, it will be better for the
surgeon to content himself with pouring fresh oily solution upon the exterior
of the cloth without disturbing it, taking care that the oil enter well beneath its
margins. I would advise that this should be done in preference where a large
number of wounded have to be treated by one surgeon.
The strong oily solution (1 to 5) would irritate the skin if used continuously :
after the first dressing a solution of half the strength should be employed, and
after a few days it may be reduced to 1 to 20 if excoriation should occur.
The times of changing the outer cloth, or treating it with fresh oil, should
be in accordance with the amount of discharge. During the first twenty-four
hours the effusion of blood and serum is necessarily profuse, and it will be well
that fresh oil be applied to the outer cloth within twelve hours of the first dress-
ing, or even in six hours if there should be unusual oozing. On the second day,
also, in the case of a large wound, two dressings in the twenty-four hours will
be desirable. After this, if all go well, the discharge will diminish quickly, and
a daily renewal of the antiseptic supply will be sufficient ; and when five or six
days have passed, to apply the oil once in two days will be all that will be
required. This, however, should be continued after discharge has ceased entirely,
till sufficient time has passed to ensure that the wound has healed by scabbing,
or at least has been converted into a superficial sore.
The earlier the case comes under treatment the greater will be the prospect
of success, but even after the lapse of thirty-six hours it need not be altogether
despaired of.
164 ANTISEPTIC TREATMENT OF WOUNDED SOLDIERS
In the case of compound fractures, the essential objects of the treatment
may be attained by using splints constructed of stout iron wire bent into the
form of the margin of a lateral splint, and strengthened by cross-pieces here
and there. Such splints can be readily extemporized by the surgeon himself,
by help of two pairs of wire-forceps. The splints should be applied one at
each side of the limb, without any padding opposite the seat of injury except
the dressing above described, but padded elsewhere with any suitable soft
material, an interval being left between such padding and the dressing. The
outer layer of oiled-silk or gutta-percha should be applied outside the splints,
so that all that will be requisite in order to apply oil to the outer cloth will be
to take off the oiled silk with its retaining bandage, and pour on the oil through
the ample intervals between the wires. Or the splints might be applied im-
mediately external to the bandage that retains the deeper layer of gutta-percha,
leaving the outer cloth to be wrapped round external to the splints, cotton or
charpie imbued with the antiseptic oil being tucked in under the splints to
keep the margins of the gutta-percha in apposition with the limb, the cotton
being changed as often as the cloth itself.
For the sake of the general healthiness of the atmosphere of the crowded
military hospitals, it is extremely desirable that even superficial granulating
sores should be treated antiseptically. This may be done consistently with
rapid healing by washing the sore with watery solution of carbolic acid (one to
twenty), and covering it with two or three layers of oiled silk smeared with the
oily solution (one to twenty), with well-overlapping folded cloth steeped in
similar oil, and over all a piece of gutta-percha tissue and bandage.
I have suggested in the above method the employment of such materials
as are likely to be accessible to the surgeons of both armies. Other means
exist, In some respects very superior. But the supply of these is at present
limited, and those who possess them probably understand their use.
ON A CASE ILLUSTRATING THE PRESENT ASPECT
OF THE ANTISEPTIC TREATMENT IN SURGERY
[British Medical Journal, 1871, vol. i, p. 30.]
A YOUNG man, eighteen years of age, was lately admitted under my care
in the Royal Infirmary on account of impaired usefulness of the right arm,
resulting from an accident which befell him three months previously, when the
handle of a winch, revolving with great rapidity, struck the limb at the posterior
aspect, about three inches below the elbow, breaking the ulna and dislocating
the upper end of the radius forwards, the lower ends of the bones of the forearm
being tilted backwards to a corresponding degree. He at once sought medical
aid; but, strange to say, the nature of the injury was not recognized, and the
result was that when I saw him the fragments of the ulna were firmly united
at an obtuse angle with each other; a marked depression existing posteriorly
over the seat of fracture, while the head of the radius formed a prominence
at the anterior and outer aspect of the joint, being securely maintained in its
abnormal position through the connexion of the other end of the bone with
the lower end of the ulna. The elbow could not be flexed beyond a right angle,
so that he could not put his fingers to his mouth ; and, although the hand could
be rotated passively, he was quite unable himself to execute pronation or
supination. He also complained that the limb was so weak that he could
not lift any heavy object from the ground, and expressed great desire to
have this faulty state of matters rectified.
It was plain that before an attempt at reduction of the dislocated radius
could be made with any chance of success, it would be necessary to break again
the united ulna. But, considering the length of time that had passed since
the accident, and the slightness of the leverage that could be obtained upon
the seat of fracture so near the elbow, it seemed hardly likely that this object
could be attained without a cutting operation. And even supposing the bone
to give way, I felt it very doubtful whether the dislocation could even then
be reduced, both on account of its long duration and because the angular form
which the ulna had assumed implied a shortening of the forearm, which at that
late period necessarily affected all its textures. On the other hand, there could
be little doubt that, if the ulna were exposed and divided, and if, further, the
head of the radius were removed, the limb could be at once restored to its proper
166. ON A CASE ILLUSTRATING THE PRESENT “ASPECE
form. But to do this would be to make voluntarily a compound fracture of
the ulna and a compound dislocation of the elbow-joint—a procedure which, under
ordinary treatment, I should have regarded as unjustifiable. But with the
means now at our disposal of guarding against the mischievous influence of
external agents upon wounds, I believed that these two operations could be
performed without any chance of mischief resulting. Accordingly, at a clinical
lecture on December 12, 1870, having explained the aspect of the case, and
having failed to rebreak the ulna by very forcible measures under chloroform,
I first washed the skin of the forearm and elbow with 1 to 20 watery solution »
of carbolic acid, to destroy all putrefactive particles in the epidermis and hair-
follicles, and then made a longitudinal incision about two inches long over the
back of the ulna where it had been broken, while an assistant threw over the
part a cloud of spray of 1 to 40 carbolic lotion by means of Richardson’s
apparatus ; and, having sufficiently detached with the knife the muscles from
the bone, and ascertaining precisely with the finger the situation of the callus,
I inserted the blades of a pair of strong bone-pliers, smeared with an oily solution
of the acid (zr to 10), and, cutting through the bone, used the pliers as a powerful
lever to wrench the fragments sufficiently apart, and detach them enough from
surrounding soft parts to ensure free mobility, the antiseptic spray being mean-
while constantly maintained. A sponge wrung out of 1 to 40 watery solution
having then been bandaged upon the wound, I made an attempt to reduce the
dislocation of the radius; but, meeting with the failure I had anticipated,
I at once cut down upon its head in a cloud of spray, and removed it by nipping
through its neck with the pliers, the blades of which had been again smeared
with the oil. A folded cloth dipped in the watery solution having been laid
upon the wound, I had the satisfaction of finding the forearm assume, under
moderate extension and coaptation, a perfectly normal shape. The limb was
then enveloped in lac-plaster from the middle of the arm to the lower part of
the forearm, the sponge and cloth having been previously removed under the
spray, the wounds being left unstitched, to secure complete absence of tension
from accumulating blood or serum. Cloths to absorb discharge, and a roller
smoothly applied so as to adapt the plaster well to the limb, and a pair of
Gooch’s splints, anterior and posterior, with a special pad in front over the seat
of fracture, completed the dressing, the elbow being kept at a night angle.
Next day, the dressings were entirely changed, when it was found that
a good deal of blood and serum had oozed into the cloths. The lac-plaster
was cut up with scissors along a line distant from the wounds ; and, as it was
raised from the limb, the spray of I to 40 lotion was made to play beneath it.
The gaping wounds were found filled with blood-clot, while the limb was, free
OF THE ANTISEPTIC TREATMENT IN SURGERY 167
from swelling, redness, or tenderness. The limb having been washed from
bloody stain with a cloth dipped in 1 to 40 lotion, while the wounds were kept
covered with bits of rag wrung out of the same, oiled-silk ‘ protective ’,1 dipped
in the lotion to give it a temporary antiseptic film, was placed upon each wound
to protect it from the stimulating action of the acid in the lac-plaster, which was
then wrapped round the limb in two layers, extending several inches beyond the
‘protective’ in every direction, after which the splints were reapplied as before.
This dressing was left unchanged for two days, after which the patient
was again dressed in a precisely similar manner before the clinical class, walking
into the theatre and upstairs again to his bed just like a person affected with
a simple fracture or dislocation. His pulse was 70, his temperature 98-2, and
he was entirely free from pain. The stain on the cloths corresponded to about
half a drachm of bloody serum; the clots remained unaltered in appearance
in the wounds, and the limb in the vicinity had still a perfectly natural aspect.
Feeling sure that the discharge would now be very shght in amount, I left this
dressing untouched till the following lecture, four days later, or just one week
after the operation, when the wounds were again exposed before the class. All
remained the same, except that while there was no pus, and merely a stain
corresponding to a few minims of serum as the product of both wounds for four
days, the blood-clots had been extensively converted into vascular tissue, while
some portions yet unvascularized had assumed a grey or yellowish colour, and
in both wounds there was a broad cicatrizing margin. Healing, though under
a moist dressing, was going on as under a scab ; or, in other words, putrefaction
being excluded by means of an efficient antiseptic guard, while the exposed
tissues were protected from the action of the antiseptic salt by the interposition of
a layer of unstimulating material, the disturbing influence of externalagency was
avoided, and we attained very closely to the conditions of a subcutaneous injury.
On this occasion, instead of the lac-plaster, a folded muslin cloth, of open
texture, imbued with a mixture of paraffin, resin, and carbolic acid, was em-
ployed to combine the functions of the lac-plaster and absorbing cloth. Hitherto
I have been opposed to porous antiseptic dressings, having observed that, when
in the form of lint steeped in an oily solution of carbolic acid, the discharge,
if at all free, washed out the antiseptic liquid from among the neutral fibres,
and opened a way for the penetration of putrefaction. But, having heard
* This protective is made by varnishing oiled silk on both surfaces with copal varnish, which renders
it considerably less permeable to carbolic acid, and when dry it is brushed over with a mixture of starch
and dextrine to give it a film of material soluble in water, so that it becomes uniformly moistened when
dipped into the antiseptic lotion. When it is not at hand, common oiled silk may be used as a substitute
for it, if smeared with an oily solution of carbolic acid, and used in two layers to make up for its inferior
efficiency. [See also pp. 184-5 of this volume.]
168 ON A CASE ILLUSTRATING THE PRESENT ASPECT
reports from various quarters of the efficacy of oakum, I have lately put it to
the test with granulating sores, where, if it should happen to fail, no mischief
would result, and I have found it more than answer my expectations. The
reason for its superiority over oily cloths is readily intelligible. Each fibre
of the oakum is imbued with an insoluble vehicle of the antiseptic ; so that
the discharge in passing among the fibres cannot wash out the agent any more
than it can when flowing beneath the lac-plaster, to a narrow strip of which
an individual oakum fibre is fairly comparable. I may remark as worthy of
notice by those who still cling to the idea that carbolic acid has some unknown
virtue distinct from its antiseptic property, that oakum contains none of that
substance, but creosote and probably other antiseptic hydro-carbons, the effects
of which in preserving smoked meat are familiar.
Oakum not only proved efficient antiseptically, but presented several
advantages over lac-plaster. When the latter is left as a dressing for several
days together, the discharge, even though small in amount, soaking into the
absorbing cloths, loses the carbolic acid it had received from the plaster, and,
putrefying from day to day, assumes an acrid character, and sometimes pro-
duces most troublesome irritation of the skin. This is, of course, avoided by
the oakum. Again, the lac-plaster being quite impermeable to watery fluid,
keeps the skin beneath it moist, and, in fact, covered with a weak watery solu-
tion of carbolic acid, which, I suspect, insinuates itself, more or less, beneath the
protective, and maintains a slight stimulating influence upon the parts beneath
into it. But oakum, draining away the discharge as fast as it is effused, avoids
this source of disturbance. The result is, that if a granulating sore is thoroughly
washed with an antiseptic lotion and covered with ‘ protective’ and a well-
overlapping mass of oakum secured with a bandage, a dressing is provided
which nearly approaches the ideal I have long had in view. For, as granula-
tions do not form pus or even exude serum except when stimulated, a persistent
antiseptic, combined with an efficient protective, should constitute a more or
less permanent dressing under which discharge should cease and cicatrization
proceed with great rapidity. Accordingly, ulcers of the leg treated in this way
have been found, when exposed after the lapse of several days, either entirely
healed or greatly advanced in the process, while the moisture beneath the
protective has been of a serous character and the discharge collected in the
oakum comparatively small in amount. Lastly, the lac-plaster has this further
disadvantage from the moisture beneath it, that it prevents efficient strapping
in cases that require it. But under oakum an adhesive plaster retains its hold
as well as under dry lint.?
* Antiseptic adhesive plaster is readily improvised by dipping ordinary strapping in a hot solution
OF THE ANTISEPTIC TREATMENT IN SURGERY 169
But while oakum has these great advantages, it is disagreeable to many
persons from its strong tarry smell; and I have been lately endeavouring to
apply the oakum principle in some shape free from this objection. Oakum
consists of the detached fibres of old ropes which had been treated with Stock-
holm tar, among the constituents of which is common resin. I happened to
notice, several years ago, that resin holds carbolic acid with remarkable tenacity,
so that if one part of the latter be mixed by melting with five of the former,
the glutinous mixture which results on cooling communicates only a slight
warm taste to the tongue, though containing so large a proportion of the pungent
antiseptic. But this material is of itself too sticky for the purpose, and resin
is, besides, somewhat irritating to delicate skins. Paraffin, another constituent
of tar, is remarkable for its entire absence of adhesiveness, as well as for its
perfect blandness; but when pure, though it may be mingled with carbolic
acid in the melted state, it separates entirely on cooling. If, however, the
three ingredients be melted together, the resin, though intimately blending
with the paraffin, still retains its hold upon the acid after cooling, and by a
proper proportion between them, a product is obtained which, while inter-
mediate in physical properties between the glutinous resin and the powdery
paraffin, is unirritating to the most sensitive skin and highly retentive of the
acid, while almost destitute of odour.!
Cheap muslin gauze dipped in the melted mass, and well wrung or pressed
while hot, is an elegant and convenient form of modified oakum. It should
be folded into about eight layers; and in order to prevent the discharge
from soaking too directly through it, a piece of thin gutta-percha tissue may
be placed beneath the outer layer to guide the fluid towards the edge of the
cloth.
Such was the dressing employed a week after the operation. Three days
later, the wounds were found still healing rapidly without suppuration, and,
on rotation of the hand, the end of the radius was felt moving in its proper
place, while the ulna presented a slight convexity backwards, instead of its old
concavity. The patient who had been till then confined for the most part
of carbolic acid made by mixing one part of 1 to 20 lotion with about two parts of boiling water. When
used in this way, strapping will adhere to a moist skin, so that it may be applied under the spray when
circumstances render this desirable.
* The proportions which I have hitherto found to work best are, sixteen parts of paraffin, four
parts of resin, and one part of crystallized carbolic acid. Iam far from supposing that this first attempt
at improving upon oakum affords the best result attainable ; and I propose to institute experiments
with various other constituents of tar. But it seems worth while to mention the result already arrived
at, because, while it certainly works well in practice, its constituents are obtainable where lac-plaster
may not beso. It has the further advantage of being a very economical dressing. For the gauze loses
the paraffin and resin entirely when washed in boiling water, so that it may be used over and over again,
while about a halfpenny covers the expense of the ingredients required to charge a square yard.
LISTER II N
170 ON A CASE TEEUSTRATING SEE (PRESENT ASEE er
to bed, as a matter of precaution, was now allowed to get up, a similar dressing
of ‘ protective’ covered with antiseptic gauze having been applied.
Four days afterwards, on December 26, the dressing was again changed,
when the wound over the ulna was found almost healed, and that over the joint
far advanced in cicatrization, while there was still no pus or putrefactive odour,
and the general health of the patient continued excellent.
In some respects it would have been more satisfactory if sufficient time
had passed to permit reunion of the ulna, so that the usefulness of the limb
might be tested. But as an illustration of antiseptic treatment, the case is
already complete. In this respect, I cannot but hope that it will be thought
instructive. It is an example of a procedure, otherwise highly dangerous, if
not unwarrantable, rendered not only legitimate, but entirely free from risk,
simply because, from the circumstances of the case, and the improved means
at our disposal, we could calculate with certainty on avoidance of putrefaction.
I venture to draw special attention to the use of the spray. In every wound
treated antiseptically, two things are always to be attended to: first, to leave
the wound free from living putrefactive organisms, and, second, to employ such
an external dressing as shall securely prevent the entrance of such organisms
at any subsequent period of the case. The latter point has, in most cases,
been for a long time past satisfactorily accomplished ; but the former, till we
used the spray, was always a matter of more or less uncertainty. A floating
germ might enter during the operation into some cellular interstice among the
tissues, and, becoming surrounded with a clot of blood, might escape the action
of the antiseptic lotion with which the wound was washed, and, retaining
its vitality, might subsequently propagate its kind, and spread putrefactive
fermentation through the wound. But by help of the spray we operate in an
antiseptic atmosphere, and effectually prevent putrefactive organisms from
ever entering the wound alive. We thus dispense with the necessity for washing
the wound at all with an antiseptic lotion, and in the particular case above
related, not even the vapour of carbolic acid penetrated into the deeper parts
of the wounds, which were thus left as free from irritation as if they had been
made subcutaneously.
The spray is also of the greatest value during the stitching of such wounds
as require it, and rids us of the troublesome and uncertain process of distending
the wound with lotion by means of a syringe, after the introduction of the last
suture. In the changing of dressings, also, the spray is in some cases, and
especially in stumps after amputation, a great element of security.
Revision of the proof (January 11, 1871) affords me the opportunity of
giving another report of the progress of the case. On dressing the limb yester-
OF THE ANTISEPTIC TREATMENT IN SURGERY 171
day, after an interval of five days, I found the ulnar wound entirely healed,
while at the site of the radial incision two or three granulations about as large
as pins’ heads alone remained to cicatrize, and an odourless serous stain of
about a minim upon the gauze was the only appearance of discharge. The
ulna seemed already firmly united; and, after performing passive motion
throughout the range of the natural movements of the joint, I directed him to
try its powers. He could himself pronate and supinate the hand, could extend
the arm completely, and readily put his fingers to his mouth; and he lifted
a heavy pair of tongs, exhibiting already a strength very superior to that which
he had before the operation.
THE ADDRESs IN” SURGERY
DELIVERED ON AUGUST io, 1871, TO THE THIRTY-NINTH ANNUAL MEETING OF THE
BRITISH MEDICAL ASSOCIATION HELD IN PLYMOUTH
[British Medical Journal, 1871, vol. il, p. 225.]
Mr. PRESIDENT AND FELLOW ASSOcIATES.—My duty on the present occa-
sion is to endeavour, if possible, to give you an address commensurate in interest
with the very high honour of being selected to deliver it. With this object,
instead of attempting a general review of surgery, which has been presented
under various aspects by my able predecessors, I have concluded to bring before
you a subject which, though in some respects a special one, is calculated, as
I believe, to revolutionize almost every department of surgical practice ; I mean
the antiseptic system of treatment. The fact that my name is associated with
this topic tended to make me shrink from such a course; but, on the other
hand, I could not but feel that this very circumstance has led in all probability
to my standing before you to-day, so that you might naturally expect to hear
something from me on this subject, while it is at the same time my sincere
conviction that I could not turn the present occasion to better account than by
~ exciting in you a keener interest in the antiseptic system than it has yet elicited,
and by placing you more in a position to diffuse its benefits among mankind.
Among the causes which have hitherto interfered with the general accep-
tance of this mode of treatment, by far the most prejudicial is the doubt of its
fundamental principle, instilled by various authors who have opposed the germ
theory of putrefaction, and who, supposing themselves to be advocating the
cause of truth, have not only, as it appears to me, espoused the side of error,
but have unconsciously inflicted an amount of material evil upon their fellow
creatures such as mere speculative opinion is seldom able to produce. For
few medical men in active practice have the leisure to sift and weigh the facts
and arguments of such a discussion ; yet, if they lose firm faith in the guiding
principle of the treatment, the attainment of a full measure of success becomes
with them a matter of impossibility. ‘Felix qui potuit rerum cognoscere
causas ’ was never more applicable than here.
Another great cause of failure, and consequently of dissatisfaction with
the system, is the want of practical initiation into the treatment. For, greatly
as our means of carrying out the principle have improved of late, both in
simplicity and in efficiency, mere description seems inadequate to convey a clear
ADDRESS DELIVERED BEFORE BRITISH MEDICAL ASSOCIATION 173
idea of the method of employing them. Hence, while there are now scattered
up and down in this country and in various other parts of the world, gentlemen
who, having witnessed the treatment in our wards, whether as students or as
qualified practitioners, are attaining exactly the same kind of results as we do,
success seems a rare exception for any who have not had such opportunities.
I propose, therefore, in the first place to bring shortly under your notice
some considerations relating to the theoretical basis of the treatment ; secondly,
to exhibit before you the chief means that we now employ, and, so far as this
can be done upon a table, the mode of using them; and lastly, by your per-
mission, to state some facts which I hope you may regard as sufficient evidence
that, by such means employed on such a principle, we have it in our power
to obtain easily and securely results of a kind that without antiseptic manage-
ment the surgeon would not be justified in aiming at.
With regard to the theory of the treatment, I propose to avoid all doubtful
disputations, and simply bring before you a few facts, to which I invite your
earnest attention and your candid judgement.
Those of which I have first to speak have reference to the well-known
experiment of Pasteur of boiling a putrescible liquid in a flask with an attenuated
and contorted neck. It is now nearly four years since I introduced portions
of the same specimen of urine into four glass flasks, so as to make each about
one-third full, and, after washing their necks, drew them out with a spirit-lamp
into tubes less than a line in diameter, and then bent three of them at various
acute angles, while the fourth was left short and vertical, though equally narrow.
Each flask was then boiled for five minutes, the steam issuing freely from the
orifice ; after which they were left with the ends of the necks still open, so
that air might pass in and out freely in obedience to the condensation and
expansion caused by the diurnal changes of temperature. The boiling, I need
hardly say, was for the purpose of killing any organisms contained in the liquid
or adhering to the sides of the glass: the bending of the necks in three of the
flasks was with the view of intercepting particles of dust, which, according to
the germ theory, are the cause of putrefaction, as distinguished from the
atmospheric gases; while the fourth neck was left short and vertical for the
sake of contrast, to afford opportunity for dust to fall into the liquid, where
such portions of it as had the nature of living organisms might propagate and
induce in the fluid any changes of which they were capable. The result was,
that in the vessel with short and upright neck two different kinds of fungi,
visible to the naked eye, soon made their appearance, and these grew steadily
till they had attained large dimensions, the liquid meanwhile gradually changing
from its pale straw colour to a deep amber tint, implying alteration in its chemical
174 THE ADDRESS IN SURGERY DELIVERED BEFORE
constitution. But in the flasks with bent necks the fluid remains to this day
entirely unaltered! I regret that the distance from Edinburgh to Plymouth
is too great to permit me to bring these objects before you. One perilous
journey they have already had, when I took them from Glasgow to Edinburgh
nearly two years ago, nursing them carefully during the railway journey, to
the amusement of my fellow travellers; and in the drive from the station to
my house the violent rocking of the vehicle churned up their contents till the
upper part of the body of each flask was full of a frothy mixture of the putrescible
liquid with the atmospheric gases ; yet no harm resulted, and the fluid in the
bent flasks still retains its original pellucid clearness and pale hue. Bringing
these in imagination before you, as represented in this diagram, consider what
these facts imply. Let us not push them one tittle beyond their inevitable
interpretation. The drops of moisture deposited in the bent tubes from con-
densation of the steam when the lamp was removed dried up in a few days,
so that the necks have been for nearly four years open and dry from end to
end. Comparing the capacity of the part of the body of the flask containing
air with that of the narrow neck, it is manifest that a considerable portion of
fresh air has passed into the flask every night, in consequence of the fall of the
temperature, a corresponding portion passing out again by day, though not
the same which entered; for the diffusion of gases would ensure its mixing
freely with that previously present. Hence, during nearly four years this
putrescible liquid, this boiled urine, has been freely exposed to the influence
of the atmospheric gases, yet it has not putrefied. About half a year after
the commencement of the experiment, I decanted a little of the liquid from
one of the bent flasks into a wine-glass, and found it sweet in odour and faintly
acid to test-paper, while an honest search with a powerful glass failed to detect
even the minutest organism. Covering the glass to prevent evaporation, I found
it in two days stinking, while under the microscope it already teemed with
various organisms, and a few days later it showed fungi to the naked eye. Thus
the fluid was demonstrated to be still putrescible and a favourable nidus for
organic development ; yet both these changes have been prevented for nearly
four years by the circumstance that the air, in gaining access to it, had to pass
through a narrow bent tube of clean dry glass. Nowsuch a tube could not by
possibility arrest any atmospheric gas. It cannot possibly have stopped any-
thing but the atmospheric dust. It follows, therefore, not as a matter of theory,
but as an inevitable inference from fact, or, in other words, as a truth, that,
so far as this particular instance of a putrescible liquid is concerned, both the
* Some minute shining crystals have of late been deposited on the bottom of the flasks, probably
from condensation through the very slow evaporation constantly going on.
THE BRITISH MEDICAL ASSOCIATION 175
development of such organisms as the microscope enables us to detect, and
the concomitant putrefactive changes, are occasioned by particles of dust
suspended in the atmosphere, but not by the atmospheric gases. I confess, Mr.
President, I am ready to blush for the character of our profession for scientific
accuracy when I see the loose comments sometimes made upon this experiment ;
and I am tempted to doubt whether some of the commentators can have enjoyed
the advantages of sufficient education either in chemical physics or in logic.
The simplicity and perfect conclusiveness of the experiment constitute its
great charm, and render it, as it appears to me, deserving of your careful con-
sideration. Yet, having before published an account of it, although nearly
two years have since elapsed, so as to add considerably to its weight, I do not
know that I should have felt justified in bringing it forward on the present
occasion, if I had not an additional fact to communicate respecting it besides
the results of further lapse of time. We have seen that we have been forced
to the conclusion that, though the gases of the air certainly pass into the body
of the flask and out again every twenty-four hours, its dust, even though of
extreme minuteness, must be arrested by the contorted tube. Now, inevitable
as this inference is, it will be satisfactory to have it converted into the position
of an observed fact. This Professor Tyndall’s simple but beautiful mode of
investigation with a condensed beam of light has lately enabled me to do.
Having prepared two dry glass flasks, one of them having the neck drawn out
and contorted, I arranged them, through the kind assistance of my colleague,
Professor Tait, so that the body of each was pierced by a beam of highly con-
densed sunlight in an otherwise dark apartment. The beam, scattered by the
floating particles of dust, showed white in the surrounding darkness, within
the flasks as well as without, proving that the air within the flasks was dusty
like that outside. I now closed with sealing-wax the orifice of the unbent
flask, and, leaving the other open, allowed both to remain undisturbed in the
laboratory. A fortnight later I again submitted them to the solar beam,
condensed as before, and now found that in both flasks alike the visible part
of the beam terminated abruptly at the glass on each side, showing that in
both the air was, as Tyndall expresses it, ‘ optically empty,’ or, in other words,
that it was destitute of even such minute particles of floating matter as could
produce the faintest nebulosity. During the time between the two observations,
the force of gravity had led to the subsidence of even the minutest floating
particles ; and, though the changing temperature of the laboratory had of
necessity induced the daily entrance of air into the open flask, the bent form
and fine calibre of the tube by which it was admitted had effectually filtered it
of suspended material, though in a very dusty apartment.
176 THE ADDRESS IN SURGERY DELIVERED BEFORE
The other class of facts in this division of the subject to which I am anxious
to direct your special attention was also suggested by one of Tyndall’s experi-
ments with the condensed luminous beam—that, namely, in which he proved
the perfect manner in which cotton-wool filters the air of its suspended particles,
by blowing against the beam with a pair of bellows having a mass of the cotton
tied over the nozzle; the result being that the beam, elsewhere white from
illuminated dust, became perfectly black at the part on which the current was
directed through the cotton-filter: hence the idea naturally suggested itself
that cotton-wool might be used with advantage as an antiseptic dressing.?
Of course it would be useless to apply ordinary cotton without special pre-
cautions, for, according to the germ theory, putrefactive particles must exist
among the fibres and lie scattered over the wool. But if the cotton were
impregnated with some volatile material capable of destroying the vitality
of the septic organisms, and then placed upon the wound after washing it with
a lotion containing the same substance in solution, the result ought to be,
supposing the theory true, that, after the volatile antiseptic had become dissi-
pated by diffusion from the dressing and from the wound, the cotton-wool,
though destitute of any chemically antiseptic properties, should effectually
prevent, by its filtering property, the access of any putrefactive agents, and
keep the wound sweet, while in itself a perfectly bland and unstimulating
application. Accordingly I prepared four samples of cotton-wool by diffusing
through each one of the following substances—chlorine gas, sulphurous-acid
gas, carbolic-acid vapour, and the vapour of benzene—four materials very
dissimilar in chemical properties, but having a common hostility to low forms
of life. Chlorine, sulphurous acid, and carbolic acid are well known to have
such a property ; and, knowing that benzene is used by the entomologist for
killing insects, and having ascertained by experiment the potency of its vapour
for the destruction of pediculi, I thought it probable that it would also answer
our purpose. I then dressed with these four kinds of prepared cotton-wool
various suppurating sores, excoriations, and contused wounds, after washing
the surface with the corresponding lotion, or, in the case of benzene, with the
undiluted material. The result in every instance corresponded exactly with
theory. After about twenty-four hours’ exposure at the temperature of the
body, the cotton-wool was found to have lost the odour of the antiseptic, yet
the blood, serum, or pus, as the case might be, remained perfectly sweet for
* My friend Dr. Meredith, of the Indian Service, who attended Tyndall’s first lecture on ‘ Dust
and Disease’, just after a visit to Edinburgh, where he had been greatly interested with the antiseptic
treatment, at once wrote informing me of this experiment, and asking if I did not think that cotton-wool
might be turned to account for excluding the causes of putrefaction from wounds—a suggestion which
I at once proceeded to act upon as above described.
THE BRITISH MEDICAL ASSOCIATION 177
an indefinite period, while healing advanced in the satisfactory manner that
might be anticipated from the absence of all irritating quality in the dressings.
There was, however, one circumstance, highly instructive in itself, which inter-
fered sadly with the utility of this application ; namely, that if the discharge
happened to be sufficiently copious to soak through the cotton-wool and appear
at its external surface, putrefaction occurred throughout the entire mass of the
moistened part down to the wound, even within the first twenty-four hours
after the dressing, if the fluid were sufficiently copious to penetrate within that
period. It is only when dry that cotton-wool can arrest the progress of micro-
scopic organisms, which have ample room to develop among its meshes when
filled with a putrescible liquid.
And now, Gentlemen, allow me, at the risk of seeming tedious, to endeavour
to bring home to you a little more closely the inference that is to be drawn
from these facts. But, first, let me describe in detail the manner in which
the dressing with carbolated cotton-wool was practised. The cotton-wool
having been impregnated with about a two-hundredth part of its weight of
the acid in the form of vapour, the surface of a granulating sore or abrasion
was washed, together with a portion of the surrounding skin, with a solution
of the acid in about forty parts of water. A piece of oiled silk of the size of
the sore was then applied, to prevent the dressings from sticking through dryness.
Over this was placed a piece of folded linen rag, rather larger than the oiled silk,
and impregnated with the carbolic-acid vapour in the same manner as the
cotton-wool ; the object of the rag being to absorb the discharge and prevent
it from trickling down, as it was otherwise apt to do, below the slightly absorbent
cotton, involving its early appearance at the surface and consequent spread
of putrefaction to the wound. Lastly, a well-overlapping mass of the carbolized
cotton-wool was securely fixed by a bandage. The result, as before stated,
was that, though all chemical antiseptic virtue left the dressing within a day
or two, putrefaction was excluded by the cotton-wool for any length of time,
provided the discharge did not penetrate to the exterior of the mass. Consider,
now, the circumstances of the serum or pus that oozed from beneath the edges
of the oiled silk into the folded rag—let us suppose a week after the applica-
tion of the dressing, when all traces of the volatile antiseptic had certainly
disappeared. Here was a highly putrescible liquid, not subjected to boiling,
as in the flask experiment, or acted on by any chemical agent whatever, yet
remaining free from putrefaction in a rag moistened with it at the temperature
of the human body, simply because it was covered over with pure dry cotton-
wool. How, then, did this cotton-wool exclude the causes of putrefaction in
the atmosphere? It certainly did not keep out any of the atmospheric gases.
178 THE ADDRESS IN SURGERY DELIVERED BEFORE
The same cause that led to the escape of the volatile antiseptic necessarily
occasioned a perpetual intermingling between the external air and that between
the meshes of the fabric, as any one acquainted with Graham’s beautiful
researches into the laws of gaseous diffusion must at once admit. The only
constituent of the atmosphere which the cotton-wool could possibly exclude
is its dust ; and this we know, from Tyndall’s experiment, it did exclude. Here,
then, we have another inevitable inference from fact, another truth, and that
in itself all-sufficient, with reference to the antiseptic system of treatment ;
the truth, namely, that pus, blood, and the dead tissues in contused wounds
do not putrefy through the influence of the atmospheric gases, but through the
operation of particles of dust, which may be permanently deprived of septic
energy by the vapour of an agent like carbolic acid. I do not ask you to believe
that the septic particles are organisms. That they are self-propagating, like
living beings, and that their energy is extinguished by precisely the same
agencies as extinguish vitality, such as heat and the various chemical substances
to which I have referred, is certain, and is of the utmost practical importance.
But if any one, in spite of these facts, and in spite of the strong analogy of the
yeast plant, and the various kinds of fungi which we term mould, prefer to believe
that the septic particles are not alive, and to regard the vibrios invariably
present in putrefying pus or sloughs as mere accidental concomitants of putre-
faction, or the results, not the causes, of the change, with such a one I, as
a practical surgeon, do not wish to quarrel. Nor do I enter upon the question
whether spontaneous generation can take place at the present day upon the
surface of our globe. To do this, would be to engage in doubtful disputations,
which I promised to avoid.
But I do venture earnestly to beg of all of you who are engaged in surgical
practice, that you will give these simple facts your careful consideration ; and
if you think the interpretation I have given a sound one, do not let any state-
ments, whether in books or in journals, shake your belief in the truth that
putrefaction, under atmospheric influence, as it occurs in surgical practice, is
due to particles of dust ever present in the atmosphere that surrounds our
patients, and endowed with wonderful chemical energy and power of self-
propagation, yet happily readily deprived of energy by various agents which
may be employed for the purpose without inflicting serious injury upon the
human tissues. With this as your guiding principle, you will find yourselves
successful with the antiseptic system of treatment ; but without it, whatever
theory you adopt, you will ever be walking in the dark, and therefore ever
liable to stumble.
And now I proceed to the second division of my subject—the exhibition
THE, BRITISH MEDICAL ASSOCIATION 179
of our principal means and methods of treatment. For preventing the access
of putrefactive fermentation, the agent which we now commonly use is what
we have termed the antiseptic gauze, of which these are samples—being a loose
cotton fabric, the fibres of which are impregnated with carbolic acid securely
lodged in insoluble resin, which holds the carbolic acid with remarkable tenacity,
while at the same time a little paraffin is added to prevent the adhesiveness
which the mixture of carbolic acid and resin would otherwise possess. The
interstices between the fibres are kept free from these ingredients, so that the
fabric, being porous, may be fitted for absorbing discharges. The carbolic
acid is in considerable quantity in the gauze; but it is held so tenaciously by
the resin that, on the one hand, when first applied, it is unirritating to the human
skin, and, on the other hand, unless discharge be very copious, it will retain
its virtues for upwards of a week at the temperature of the human body. Now
supposing I were going to use this gauze for dressing any case in which a copious
discharge was expected—as, for example, a large psoas abscess immediately
after it had been opened—I should take a considerable quantity of the gauze
(about as much as one can conveniently hold between the extended hands)
and fold it three times so as to make it eight layers. But there would be no
use in my having the folded gauze of this extent, if I did not adopt some means
for compelling the discharge to pass throughout the length and breadth of the
dressing ; and for this purpose some impermeable tissue must be interposed
between it and the external air. That which we have found the most con-
venient is a cheap and light form of macintosh, termed ‘ hat-lining’ by the
india-rubber dealers. I cut a piece of this, nearly as large as the folded gauze,
and then place it beneath the layer that is intended to be outward. The
discharge then coming from the wound, situated opposite the middle of the
gauze, instead of passing directly outwards through it, is compelled to traverse
all the extent of the antiseptic dressing ; and in that way, by using a sufficiently
large piece, and with this arrangement of the macintosh, you may be pertectly
certain that, if you leave no putrefactive mischief in a wound or abscess, none
will enter it, however profuse the discharge may be during the first twenty-four
hours. That is one very important point gained. As the discharge diminishes,
the intervals between the dressings are extended; and when it amounts to
only a minim or two in twenty-four hours, the application may be left undis-
turbed for a week. The gauze is also extremely convenient in the form of
bandage
in position; and instead of being a nidus for putrefaction, as a cotton-
which is put on to hold the main dressing
an antiseptic bandage
bandage would be, it increases at every turn the antiseptic efficacy of the
dressing. Besides this, the bandage having a degree of stickiness, its turns
180 THE ADDRESS IN-SURGERY DELIVERED BEFOR®
do not tend to slip as those of a cotton-bandage do, which is an additional
advantage.
Such, then, are the means by which, in ordinary cases, we ensure that
putrefactive fermentation does not extend from without into the wound or
abscess. Of course it would be of no use to apply such an external dressing
if putrefactive particles in an active state were left within a wound. Ifa wound
be presented for treatment, having been inflicted by another than the surgeon,
some dust is sure to have been introduced ; and we must first destroy its septic
energy by washing the raw surface thoroughly with some liquid trustworthy
for the purpose, such as chlorine-water, or sulphurous-acid lotion, or a strong
solution of carbolic acid, or of chloride of aluminium, for there are various pre-
parations which may be used with efficiency. But when the surgeon operates
on a previously unbroken integument, he has the opportunity of preventing
the septic particles from entering in an active state at all, by operating in an
antiseptic atmosphere. This is readily provided for in small operations by
using a watery solution of carbolic acid with Richardson’s apparatus for local
anaesthesia. For making the spray more fine, I have found it convenient to
have the lower end of the water-tube almost entirely stopped up, leaving only
very minute apertures. The result is, as you see, an exceedingly satisfactory
spray. For any small operation this answers the purpose perfectly well,
provided always that you take the precaution of having the liquid filtered
through a cambric handkerchief or some similar fabric, in order to exclude
the grosser particles of dust, which otherwise would have the effect of blocking
up the fine orifice at the nozzle of the apparatus—an occurrence which, under
some circumstances, might be disastrous in its effect.
We have lately found that the strength of the solution employed for pro-
ducing the spray may be considerably reduced. We have ascertained that it
may be used as weak as one part of carbolic acid to a hundred parts of water ;
and that a spray made with such a lotion is thoroughly trustworthy as an
antiseptic atmosphere.
The reduction of the strength of the spray is a matter of great importance.
In the first place, it 1s a great comfort to the surgeon, as I can testify from
experience. When we used a solution as strong as one part of carbolic acid
to forty parts of water, my hands were constantly in a rough and uncomfortable
state ; but when the proportion is reduced to one to a hundred for the produc-
tion of the spray, the hands experience no inconvenience whatever, and one
can even breathe with comfort in such an atmosphere.
In the second place, it is equally advantageous for the patient, because
the weaker the antiseptic application, of whatever sort it is, the less irritation
THE BRITISH MEDICAL ASSOCIATION 181
do we occasion to the tissues of the part treated with it. The antiseptic is
always injurious in its own action ; a necessary evil, incurred to attain a greater
good. To suppose that it is useful by its own operation in some specific manner
unknown to us, is an entire mistake. I know that, not only from theory, but
as a matter of experience. At one time, I used the undiluted acid; and, in
doing this, I could not avoid producing not merely irritation, but a certain
amount of sloughing. Then I used a strong solution of carbolic acid in oil ;
then a rather strong solution in water; then a weaker watery lotion; and
now we employ a solution as weak as that which I have described—one part
of carbolic acid in a hundred of water—and that applied only in the form of
spray, avoiding absolute drenching of the tissues at all, and avoiding also the
injection of the wound by a syringe, as we used to do after the operation was
completed, in order to destroy the organisms introduced ; and, in direct pro-
portion to the weakness of the solution used and to the smallness of its oppor-
tunity of acting on the tissues of the part, is the satisfactoriness of the results
obtained, provided that the essential object of avoiding putrefaction is secured.
And now, supposing that I were, single-handed, about to change the dressing
in the case to which I have alluded—a large psoas abscess—the spray is of
extreme value. I wish that the spray shall play upon the surface of the body,
in the angle between the dressing and the skin, as I lift the gauze. It would
be very inconvenient if it were necessary for this purpose always to have an
assistant to work the spray; but, by a little management, the spray can be
worked perfectly well, as you see, by the surgeon himself. [This is done by
placing the bottle of Richardson’s apparatus against the ball of the thumb,
and holding the india-rubber bulb to be compressed between the opposite side
of the bottle and the fingers of the same hand.} Supposing this were the site
of the incision in a case of psoas abscess, as long as I choose I can perfectly
protect it with the antiseptic atmosphere, and then put on what we have called,
for the sake of distinction, a ‘ guard’—a piece of rag dipped in the one to one
hundred watery solution of carbolic acid, after which the spray can be removed
with security ; the surrounding parts having then been cleansed from any
discharge there may be, the spray is once more made to play on the part during
the exposure of the wound until the permanent antiseptic dressing is reapplied.
But, gentlemen, though such a spray-producer is perfectly efficacious for
a small operation, it does not make a cloud of sufficient volume for a large one,
such as an amputation of the thigh or at the hip-joint. Therefore, with the
object of securing the same result in such cases, I have had this apparatus
prepared, which, I confess, is in a cumbrous and heavy form; but I hope it
will be improved in that respect before long. Meanwhile, it is much better
182 THE ADDRESS IN'SURGERY DELPIVERED BEFORE
than nothing. Let me say a word or two, in the first place, as to the principle
on which it is constructed. It appears that the best kind of spray which can be
produced is that which is formed on the principle of the atmospheric odorator,
by having one tube set at right angles to another, the air-tube being larger than
the water-tube, and the opening of the water-tube being exactly opposite the
middle of the orifice of the air-tube. This makes the finest and best of all sprays.
But, with a heavy apparatus like this, it would never do to have to move it
about along with the nozzle, as is absolutely necessary in the instruments of
ordinary construction on this principle. We must have tubes to convey the
air and the water to a considerable distance ; and this is very easily done by
not merely having the liquid ejected by the force of the air blown over the
orifice of the water-tube, but by having it driven through the tube by the force
of the same pump that propels the air, the quantity of the water being regulated
by astop-cock. Then it was necessary to provide some ready means of clearing
the fine end of the water-tube, in case of its obstruction by particles of dust.
This is done by having the water-tube straight for a short distance from the
nozzle, and then bent at a right angle, with a little milled cap to screw on at
the angle, so that, in case of obstruction, the cap is screwed off, and the orifice
of the water-tube is cleared at once with a needle or a bit of fine wire. I have
used this apparatus in various operations of late, among which I may mention
my two last amputations, one in the thigh, the other in the arm, in both cases
using nothing stronger than the one to a hundred solution for the spray, and
the same for the sponges ; except only, what I believe to be a wise precaution,
that, when a sponge has become soaked with blood, it should be washed first
with pure water, then dipped for a moment in a strong solution (one to forty),
and then squeezed out of a solution of one to a hundred to give it the necessary
blandness ; and in both these cases putrefaction was entirely avoided. [The
apparatus exhibited had two nozzles, attached to independent caoutchouc
tubes, furnishing large clouds of spray, that could be directed, if necessary, to
opposite sides of the part operated on. Two of Richardson’s spray-producers,
worked by two assistants, will answer the same purpose, though less efficiently. |
The antiseptic catgut ligature is used for securing the arteries while the
spray still plays over the wound. It is absolutely necessary that it should be
properly prepared. I must not enter into the method of preparation, further
than to say that catgut undergoes a remarkable change in its physical constitu-
tion when steeped for a long time in an emulsion of water and oil, so that it
becomes quite transparent, and no longer liable to become soft and slippery
when placed in water or in a watery discharge. But for this circumstance,
the animal ligature would be an impossibility ; but, if you use it properly pre-
THE BRITISH MEDICAL ASSOCIATION 183
pared, you will, I believe, see good reason to be satisfied with it. That which
I now show is extremely fine, much finer than any silk commonly employed ;
and yet with a piece like this I should not hesitate to tie the femoral artery in
a stump. If you choose to use it thicker for a large vessel, you can do so. It
is conveniently carried on a little winder, in a capsule appended to a caustic-
case. The catgut, as tied in the ordinary reef-knot with the ends cut short,
seems to me to be a perfect haemostatic. It has all the simplicity and universal
applicability of the ligature, with, at the same time, the virtual absence of
any foreign body from the wound. If putrefaction be avoided, it is rapidly
absorbed, and you may reckon as certainly on the absence of any interference
with primary union on the part of such ligatures, as if there were no ligatures
at all. Should putrefaction occur, I was at first uneasy lest the prepared catgut
might soften and permit haemorrhage. I was, therefore, at the pains to test
some of the prepared catgut in the following manner. I tied some pieces of
it at intervals round a cylinder of india-rubber, so as to pinch the india-rubber
to a considerable degree of constriction, and then introduced it into putrid
serum of blood, and kept it for a week at a temperature of about go°. At
the end of this period the india-rubber was still constricted, showing that the
catgut had retained its hold in the putrid liquid, in spite of the constant strain
of the elastic material upon the knots. No doubt, in such parts of a wound
as actually putrefy, the little bits of catgut must come away like shreds or
sloughs of cellular tissue ; but I am bound to add that this is only a matter of
presumption: for, although I have used nothing but this ligature for securing
vessels in wounds for more than two years, excepting torsion, which I com-
paratively rarely resort to, and though in certain classes of cases putrefaction
cannot be avoided, in no instance have I seen the catgut knot come
away, nor have I ever known secondary haemorrhage or abscess caused
by its use.
I have spoken of the injury that the stimulating carbolic-acid lotion inflicts
on the tissues by irritation. The great disadvantage of this is, that it causes
an unusually large flow of serum during the first twenty-four hours or more,
and you must provide a special exit for the serum, else you will have incon-
venience from tension, which will lead to suppuration, though not of the putre-
factive kind. For the purpose of guarding against this, I introduce, at the
most dependent part of the wound, a strip of lint steeped in a solution of carbolic
acid in about ten parts of olive oil, to serve as a ‘drain’. This is drawn out
under the spray in twenty-four or forty-eight hours. If you drew it out without
providing an antiseptic atmosphere, you would certainly have putrefaction.
In some cases, a fine drainage-tube is convenient for this purpose, if well steeped
184 THE ADDRESS IN SURGERY DELIVERED BEFORE
in solution of carbolic acid. For, as india-rubber happily absorbs carbolic acid,
the drainage-tube is antiseptic when introduced.
There is yet one other point to which I must allude, which is, that carbolic
acid interferes with the cicatrization of a wound, if it act directly on it. This
agent operates with special energy on the epidermis. Sometimes this is a
convenience. For example, if we dip the forefinger into a carbolic-acid lotion,
and hold it there for a second or two, we may be certain that the epidermis is
so imbued with the carbolic acid, that it is for the time antiseptic, and therefore
may be introduced into the cavity of an abscess or any other part which we
wish to explore; and very valuable an antiseptic forefinger often is in that
way. But this action of the acid on the epidermis makes it interfere with
cicatrization ; and even the gauze, though generally perfectly free from irritating
influence upon the sound skin or an old scar, will frequently, if applied directly
to a wound, entirely arrest new epidermic formation, and sometimes excoriate
a tender young cicatrix. Something, therefore, must be interposed to protect
the wound from this effect of the antiseptic. What we have generally used
hitherto for this purpose is what we have called the ‘ oiled-silk protective ’,
consisting of oiled silk varnished with copal varnish, which makes it much
less permeable to the carbolic acid. But, unfortunately, this is not a perfect
protective. It acts admirably until it becomes moistened; but afterwards
the water that penetrates the substance conveys the carbolic acid in. I have
striven in various ways to get something perfect in that way; and I have
lately been engaged in a manner which, though not yet completely successful,
may be mentioned on account of its interest otherwise. Some time since,
I tried the effect of an oil-paint on oiled silk, in the hope that the particles of
pigment, closely packed, might serve considerably to intercept the carbolic
acid, though the oily material that cements the particles is permeable to it.
The result was such as I had hoped, except that the material proved too stiff
for convenient use. A few weeks since, however, I happened to be going through
an india-rubber factory, and there I saw, among other things, the process of
mixing various pigments with caoutchouc ; and it occurred to me, might not
india-rubber, blended with some pigment, answer as a protective? The india-
rubber is permeable to the carbolic acid; but with the pigment it might not
be so. I first tried a coloured rubber that had been vulcanized, and then came
out a most curious and interesting circumstance. The sulphur in the vulcanized
india-rubber acting chemically on the discharge, the result was a stench like
rotten eggs, presenting an excellent example of decomposition without putre-
faction ; for there was no putrefactive fermentation—no spread of the decom-
position into the interior of the wound or abscess. It was limited to the exterior,
THE BRITISH MEDICAL ASSOCIATION 185
and was simply the result of the chemical action of the nascent sulphur upon
the discharges. And if, under such circumstances, we resumed the oiled silk
protective, we again had perfect absence of unpleasant smell.
The necessity for avoiding any sulphur in the material was a great cause
of embarrassment ; for, as a general rule, the admixture of any foreign ingredient
with caoutchouc causes a most inconvenient softness and adhesiveness of the
product—evils which vulcanizing completely corrects. Magnesia forms an
exception to this rule, producing with the pure rubber a very satisfactory
substance as regards its physical properties. But then we found that, in the
case of a sensitive skin, this magnesia caoutchouc produced intolerable itching
and redness, for a reason which I do not quite understand. At length it occurred
to me that perhaps shellac, which seems quite unirritating, might be mixed
with the caoutchouc ; and that this might answer the purpose. For though
shellac, when once mixed with carbolic acid, holds it very tenaciously, as is
seen in the lac-plaster with which some of you are familiar, yet the acid does
not readily penetrate into unmixed lac. When I suggested this to the managers
of the india-rubber works, they told me that they had previously ascertained
that shellac could be perfectly blended with caoutchouc; the product being
the beautiful article you now see, sufficiently tough, yet pliant, transparent,
and with no unpleasant odour, and, as I ascertained by experiment, practically
impermeable to carbolic acid. Here, then, I thought I had attained the object
at which I had been aiming for years; and already we were getting results
of a kind we had never got before: we had reached more nearly than ever
before the conditions which we know must occur subcutaneously. I had never
witnessed the healing of ulcers proceed so rapidly as I have seen it under this
protective, covered with overlapping gauze; but, to my extreme chagrin,
I have learnt within the last few days that, in two patients with very sensitive
skins, even this material produces a trifling irritation. Still I cannot but believe
that we are on the verge of getting what we want in a protective—viz. a tissue
perfectly bland and unstimulating in its own substance, and also quite imper-
meable to the antiseptic.
So much, then, gentlemen, as to our means; and now, if you will allow
me a little time longer, I will tell you what I expect will be the most interesting
to you all—the history of some cases illustrative of the effects of this treatment.
The simplest of all cases for antiseptic management is that of abscess ;
and the most beautiful, as it seems to me, in the results. It is the simplest,
because here we do not apply the antiseptic to the part concerned at all; we
* IT cannot but publicly express my thanks to the managers of the North British India-rubber Works,
for the great kindness and liberality with which they have carried out these experiments for me.
LISTER II O
186 THE ADDRESS IN SURGERY DELIVERED BEFORE
only open the abscess in an antiseptic atmosphere by free incision, pressing
out the pus—ensuring, in short, free exit for the contents, without the possibility
of the entrance of putrefaction. The antiseptic never enters the abscess-cavity
at all; and I would beg of those who still hold the view that carbolic acid exerts
its beneficial influence by acting upon the tissues of the part, to consider carefully
the case of abscess—say a psoas abscess connected with diseased vertebrae.
Under the carbolic-acid spray, a free incision is made into the cavity ; and
I may remark that the spray is of peculiar value for this purpose, because,
if an artery happen to be divided during the dissection, it can be secured without
any difficulty, or it can be tied after the abscess has been opened. As we used
to proceed, plunging in a knife, and effecting the opening at one stroke, if a deep
vessel were divided it was a matter of very great inconvenience. Suppose
now a large psoas abscess has been opened under the antiseptic spray by free
incision, we press out the pus—letting out, it may be, a quart or more; and
on the following day we find, if we have emptied the abscess thoroughly, that
there is not a drop of pus to be pressed out, and no pus is formed from that
abscess for the future. This is a thing that must be seen to be believed. It
seems so contrary to one’s experience, and yet it is exactly in accordance with
pathological theory. Now suppose a few more days have passed, probably
nothing whatever can be squeezed from the abscess-cavity ; but, if you can
squeeze out a drop of anything, it is a drop of clear serum—clear, transparent
serum. Hence, Mr. President, I say it is transparently clear that the carbolic
acid does not enter into the abscess-cavity at all. Still less, if possible, can it
penetrate to the diseased bone of the vertebrae ; because, if the carbolic acid
did enter in even a slight degree into the abscess-cavity, it would produce
opacity of the serum, from coagulating its albumen. Therefore the clear drop
which you press out is certain proof that the carbolic acid does not act on the
affected part at all.
I have here a piece of bone which came out along with the pus from a large
psoas abscess which I opened in April last—a portion of cancellated bone.
I must not hand it round, because it is precious, and one similar piece has already
been lost through injudicious exhibition. But you, Mr. President, can see
that this is cancellated bone, proving that the abscess really did communicate
with the diseased vertebrae. The patient was an adult, with an acute curvature
of the dorsal region of the spine, and other symptoms of spinal disease. He
had a sense of painful constriction round the waist, pain shooting down into
the haunches and lower limbs; and he was in a state of very great general
prostration. Still, if we had not seen these bits of bone, it might have been
said by anybody, and perhaps fairly said, ‘I do not choose to believe that this
THE BRITISH MEDICAL ASSOCIATION 187
abscess was connected with diseased bone; it may have been concomitant
with acute spinal symptoms, without being in connexion with the vertebrae.’
But the discharge of the bone with the pus makes us sure on this point. Well,
in that case the patient experienced immediate relief from his distressing
symptoms, without the occurrence of the slightest febrile disturbance ; and there
has been no discharge of pus since the evacuation of the original contents, though
up to the present time there has been still an oozing of serous fluid into the
gauze, which is changed once every four or five days. Four months, you may
say, is a long time for the treatment to have continued. No doubt it is so;
but what is the alternative ? The alternative, as we all know, either if the
abscess be opened by free incision or allowed to open itself, is almost invariably
death, either after an acute course of irritative fever, which we should all wish
to prevent, or after a long period of protracted hectic, perhaps even more
distressing. Meanwhile, the serous discharge in this case has been steadily
diminishing ; and I have reason to believe, from previous experience, that we
shall ultimately obtain a cure.
Among other cases of this kind, I may mention one as peculiarly instructive.
On the 2oth of January, 1870, I opened a psoas abscess in a man twenty-seven
years old, who from the age of eleven had had antero-posterior curvature in
the upper dorsal region of the spine. At length a psoas abscess made its appear-
ance, and, increasing slowly, extended far down into the thigh. I evacuated
between fifty and sixty ounces of thick pus, with lumps of curdy material, and
several small pieces of cancellated bone and numerous other osseous particles
came out in subsequent dressings. My friend Dr. Hector Cameron (the case
being a Glasgow one) undertook the after-management, continuing the antiseptic
dressing, and changing it, when the serous discharge became slight, every four
or five days—the lac-plaster being used ; and at length, on the 5th of February
last [1871] it was perfectly healed. Then, after giving the spine a few weeks’
more rest (for I believe, after such an abscess has completely healed, you ought
still to give the spine repose for a while, just as you would in a case of spinal
disease without abscess), that patient perfectly recovered, and is now walking
about, a healthy man. Here patience and perseverance, continued for more
than a year, were at length rewarded by success.
In connexion with these cases of abscess, there is a curious circumstance
with respect to which I must put you on your guard; that is, that sometimes
the discharge, serous though it is, soaking into the gauze, comes to stink in the
dressing, in the same sort of way as pus stinks when acted upon by the vulcanized
india-rubber, though with a different quality in the smell. Why this is, I do
not know. It seems that it is not the carbolic acid only that occasions the
02
188 THE ADDRESS IN SURGERY DELIVERED BEPORD
chemical change, for we never had such an occurrence when we used the lac-
plaster. Whether it may be the resin in the gauze, I do not know ; but certain
it is that you often have some smell ; and sometimes, instead of being merely
a faint odour of rotten hay or bad soap, it is exceedingly fetid. A few days
before I left Edinburgh, I opened, in a little sickly, dwindled child, a conjoined
psoas and lumbar abscess, associated with spinal disease. I emptied the
extensive cavity by free incision in the lumbar part, and dressed with the gauze.
Two or three days afterwards, on approaching the bed, I perceived a strong
smell ; and, on taking off the dressings, the stench was very great. As this was
the first case in which I had ever opened a psoas abscess with the one to a
hundred spray, andas I had seen regurgitation of the spray take place during the
operation, I confess I was alarmed at this foul smell; but it so happened that
I could squeeze out a very little fluid from the interior; and, taking it away
under the spray, and diffusing it upon a plate, so as to be able to estimate
accurately any odour it might have, I found that it was perfectly free from smell.
Just as in the pus under the vulcanized caoutchouc protective, there was decom-
position occasioned by the chemical action of the dressing, but no putrefactive
fermentation ; for that would necessarily have spread into the interior. We
took the course of dispensing with the macintosh among the gauze, because
my house surgeon, Mr. Bishop, has noticed that, if the macintosh be removed
so as to allow free escape for the gaseous products of decomposition, you do
not get nearly so much smell; but, if the macintosh be dispensed with, you
must use a greater thickness of the gauze, and dress daily. This was done ;
and, within a week of the opening of the abscess, the discharge was only a few
minims of serum per diem, and the boy had already picked up wonderfully in
general health.
Ligature of arteries in their continuity presents one of the most striking
illustrations of the advantages of antiseptic treatment. I have only had two
opportunities, since I published on the subject, for applying the catgut in this
way ; both of them were cases of popliteal aneurysm, and both were formidable
from having become diffuse. One of them was in a man aged forty-seven, who
had only noticed the aneurysm for five weeks, during which time it had been
rapidly on the increase, so that the patient observed a change in its dimensions
every day. On his admission into hospital, on the 31st of August, 1869, it
reached from the upper part of the ham to the top of the lower third of the femur.
At the same time it caused extreme pain, with numbness in the limb, and the knee
was bent at a right angle. I tied the femoral artery at once with a stout piece
of prepared catgut, cutting the ends close to the knot, and the result was that
within ten days the wound was a superficial sore bridged over with cicatrix,
THE BRITISH MEDICAL ASSOCIATION 189
which afterwards healed like an ordinary narrow ulcer. There was a remarkable
contrast in one particular in the treatment of this case compared with ordinary
cases. Instead of leaving the patient to lie with his limb constantly in one
position on a pillow until the time should have elapsed for the ligature to separate
by suppuration—there being no separation to take place, and as I believed,
no source of irritation present—I from the first began free movement of the
limb, and at a very early period got the knee extended, to the very great
advantage of the patient. I remember a precisely similar case in which I tied
the vessel with silk in the ordinary way some years ago, where the patient was not
able to straighten the knee for weeks after leaving the hospital; and in fact
I do not know that he is able to do so now.
The other case was much more remarkable. The patient, also aged forty-
seven, but looking more like sixty-seven, presented himself at the hospital last
summer with a diffuse popliteal aneurysm which had run an acute course, but
already extended some way up the thigh. I urged him to come at once into
the hospital. He said he had important business to attend to, and could not
do so. He came back a fortnight later with the aneurysm grown to enormous
dimensions laterally, and extending up to the junction of the middle and upper
thirds of the thigh. At the same time, partly from haemorrhage into its own
body, and partly from being worn out with the pain he endured, he was reduced
to an extreme degree, so that one of the surgeons of our hospital remarked,
‘Heisa dying man, atanyrate.’ Inhis case, also, the knee was flexed ; there was
much numbness and oedema in the foot, and no pulsation in either tibial artery.
Under such circumstances, what was to be done? To open into this enormous
mass by the old operation would be most unpromising. To amputate would,
I felt sure, be to kill the man outright. The only alternative was to tie the
artery. Considering the extent to which the huge mass had already interfered
with the circulation, it seemed extremely probable that such a procedure would
be followed by gangrene. Still it seemed to afford the only chance. Then the
next question was, Where should it be tied? The lower down, the further
from the heart, the better, if it could be safely done. But was there any choice ?
Was not the external iliac the only practicable site ?. The only part remaining
in the thigh was what I believe is rightly regarded as a forbidden region, from
the vicinity of the profunda or other considerable branches. Yet having ascer-
tained, by experiment, that an antiseptic catgut ligature does not weaken the
artery at all, and does not make secondary haemorrhage likely to occur under
such circumstances, I felt justified in putting on the ligature in this forbidden
region. It is an extremely striking fact, if we think of it, that after a large
arterial trunk has been tied, we never have haemorrhage on the second or third
190 THE ADDRESS IN SURGERY DELIVERED BEFORE
or fourth day—never practically during the first week, we may say. The external
coat, pinched in by the ligature, is always strong enough to resist the impetus
of the blood, however near the ligature may be to a branch, till the tissue has
undergone alteration, till it has become softened by the granulating process
through the irritating influence of the septic ligature. But if the ligature be
not septic, nor in any other respect irritating, there is nothing to weaken the
external coat. Why should it be weakened? On the contrary, as experiment
has shown in one instance, the catgut itself, becoming replaced by living tissue,
acts as a strengthening ring instead of making the vessel weaker. Hence I felt
justified in applying it as near as possible to the aneurysmal tumour, though
this was just about the most frequent place of origin of the profunda. Catgut
a good deal thicker than that which I have shown was used, the ends being of
course cut short, and all went well. There was no appearance of suppuration
from the vicinity of the ligature, and the enormous mass gradually became
absorbed. Being much emaciated, the man put on fat so fast that we were
deceived at first with respect to the diminution of the coagulated blood, which
was actually going on much more rapidly than we inferred from our measure-
ments. Ultimately all that great mass disappeared, and the patient, first
hobbling with crutches, then walking with a stick, is now a hale man,
using no stick at all. I should add that in the performance of the operation,
though I cut down higher up than the apparent upward limit of the aneurysm,
when I divided the deep fascia I found that the extravasated blood extended
further than the swelling, so that I cut into the coagula of the aneurysm. What
would, in all probability, have been the result of such a procedure without
antiseptic treatment ?
Mr. President, I have hitherto felt some hesitation in publishing cases of
this kind, lest I should lead my professional brethren to do that which would
only end in disaster. An eminent London surgeon wrote to me some time ago
asking for catgut, as he wished to use it for tying the external iliac. I wrote
back to him saying that if he did not feel sure he could avoid putrefaction in
the wound, I would not advise him to use catgut, because, if the wound should
putrefy, the catgut lying there, without any means of withdrawing it, would »
perhaps lead to unhealthy ulceration and so occasion secondary haemorrhage,
as happened in a case of Sir Philip Crampton’s ; which was of course not treated
antiseptically. But with the spray I feel that, in operations of this sort, safety
is a matter of certainty. Any one of you who chooses may, I believe, tie the
femoral artery with no more danger than in making a cut in the skin on the
hand; and with much less danger than making a cut in the skin on the hand
without antiseptic treatment in an ordinary hospital.
THE BRITISH MEDICAL ASSOCIATION IgI
The catgut ligature has other applications of such interest, that I must
beg you to listen to some cases in illustration of them. Those to which I wish
to refer are two of irreducible hernia, which failed to yield to the treatment
which Mr. Syme long advocated, that of keeping the patient lying on his back,
giving a spare diet, with frequent doses of castor-oil, and daily application of
the taxis. One was a ventral hernia in a young woman, originating apparently
in deep-seated abscess of the abdominal wall. It was of large size, causing
extreme inconvenience, and the treatment to which I have referred having
failed, I laid the sac freely open so as to expose the adherent intestines and
omentum which it contained, and separated the adhesions under the com-
paratively inconvenient antiseptic means which we then used, freely sponging
with r to 40 watery solution of carbolic acid, and protecting such portions of the
viscera as were not being immediately operated on by a cloth dipped in the
lotion. When the adhesions had been all detached, by tearing or by the knife,
I reduced the viscera under the antiseptic cloth as under a substitute integument,
and then pared the edges of the orifice by which the sac communicated with
the abdominal cavity [an oval aperture about three inches long], cutting off
the peritoneum from the muscular and fibrous structures, and then stitched
those edges securely with closely applied interrupted sutures of prepared catgut,
the ends being cut off near the reef-knots. The external wound was then stitched
and treated antiseptically like an ordinary one. During the introduction of
the deep stitches the patient vomited violently, so that it was only by exerting
very firm pressure that I prevented further visceral protrusion, and after going
back to bed she vomited again—a tremendous test for our catgut stitches ;
but they stood the test. The young woman left the hospital without any hernia ;
and though a very small protrusion did afterwards appear below one part of the
cicatrix, it was readily reducible and amenable to ordinary treatment by means
of a truss.
The other case was a large umbilical hernia in a cook. It interfered with
her duties very much, and at last she could hardly walk about at all. This case
was treated like the last ; but, in the absence of the spray, if I had known what
I was about to encounter, I should not have entered upon it. It was a most
laborious and protracted business, dividing very complicated intestinal adhesions
by cutting and tearing, and at the same time maintaining constant vigilance in
protecting the exposed intestines with the antiseptic cloths. The thing, how-
ever, was at length accomplished, and the entire mass was returned into the
abdomen. The edges of the deep opening were pared and sewn together closely
with catgut sutures with their ends cut short, and the external wound was
closed with carbolized silk stitches, leaving an opening for a ‘drain’. A large
192 THE ADDRESS IN SURGERY DELIVERED BEFORE
quantity of blood happened to become effused into the sac during the first
twenty-four hours, so as to reproduce the appearance of tumour, though not in
sufficient amount to cause tension, and this made the absence of putrefaction
and suppuration all the more striking. And now occurred a most unhappy
circumstance, though at the same time instructive. The patient, who, as
I afterwards learnt, had before been lable to temporary attacks of mental
alienation, became, I fear, permanently mad, and a week after the operation
she was up and walking about the ward, certainly testing the catgut stitches
most severely, yet without any bad result. When the wound had healed, she
was taken to a lunatic asylum; and I have not been able to hear of her later
than six weeks afterwards, when she left for another institution of the same
kind; but up to that period there had been no return of hernia. Thus, you
see, the catgut stitch becomes a new engine in surgery, enabling us to attach
deeply seated parts to each other, leaving the connecting medium to be removed
by absorption.
As another striking illustration of antiseptic treatment, hitherto unpublished,
I may mention a case of ununited fracture of the neck of the thigh-bone. The
patient was a fine powerful man, forty-five years of age, who had fallen down
from a cart, and broken the neck of the femur. He had been treated in hospital
elsewhere ; but, strange to say, according to his own statement, he was turned
out of that institution in five weeks on crutches, whereas he ought surely to
have had at least six weeks with the long splint ; and eighteen months after-
wards he applied to me. There were all the ordinary symptoms of an ununited
fracture of the neck of the femur. There was shortening to the extent of an
inch and an eighth, while the trochanter was correspondingly nearer to the
iliac crest than on the other side, and, instead of moving in the arc of a circle
on rotation of the limb, turned on its own axis with a crunching sensation.
The man could not raise his leg beyond a trifling degree, or turn round, as he
lay, without supporting the trochanteric region with his hand; and he could
rest no weight whatever upon the limb. Under ordinary treatment, this man
would have been condemned to a life of hopeless uselessness. But, considering
his time of life, there could be little doubt that the fracture was extracapsular,
and that, if the ends of the fragments could be brought into the condition of
a recent fracture, there would be union under proper treatment, if the man
survived. But to effect this would involve making a free external wound,
and, for aught I could tell, opening into the capsule of the hip-joint. And
would that be a justifiable procedure? Thinking the matter over, although
our antiseptic means were then comparatively imperfect, I believed I could
operate so as to avoid putrefaction ; and I felt sure that if putrefaction did
THE BRITISH MEDICAL ASSOCIATION 193
not occur, the procedure would be free from danger. Well, if I believed that
I could do it with safety, and that it would probably have the effect of restoring
the man to usefulness, it became my duty to do it; and I resolved to make
the attempt. Accordingly, on the 2nd of December, 1868, the patient having
been put under chloroform, I first moved the extended limb in all directions
with the utmost freedom, so as to break down adhesions, which gave way with
a report that could be heard all over the operating theatre. Then I applied
the pulleys, and practised extension to the utmost degree that appeared
justifiable, in order to draw down the lower fragments ; and, the patient being
placed on the sound side, with the pulleys still in operation, I cut down above
the trochanter with a free longitudinal incision, the knife being smeared with
a solution of carbolic acid, in four parts of olive oil, which was also continually
poured into the wound—a very inconvenient mode when compared with the
spray. At length, having cut down to a sufficient depth, I found, to my joy,
that the tip of my finger, dipped, of course, in the oil, could be passed between
the fragments, the ends of which, though irregular, felt smooth, as if covered with
cartilage. JI now took a gouge dipped in the oil, and roughened the edge of
each fragment, producing abundance of bone-chips. I did not think it worth
while to take out the chips ; because, supposing putrefaction avoided, I expected
the chips to be absorbed. A large piece of lac-plaster was then applied as an
external dressing ; and, while the pulleys were still acting, a long splint was
put on very firmly, with iron bars substituted for the wood opposite to the seat
of operation, to permit access for dressing. See p. 156 of this volume.
198. ADDRESS IN SURGERY TO BRITISH MEDICAL ASSOCIATION
Mr. President, before I sit down, I must make an apology for the large
share which my own performances have had in this address. For this defect
I crave your kind indulgence, and only beg you to believe that I am actuated
by other than selfish motives. For sure I am that, however much the means
of carrying out the antiseptic principle may come to vary from those which we
now use, the principle itself will certainly be ultimately recognized as the most
important of all those that shall guide the practice of surgery ; and the sooner
our profession is aware of this, the better will it be for suffering humanity.
ON ANTISEPTIC DRESSING UNDER SOME CIRCUM-
STANCES OF DIFFICULTY, INCLUDING
AMPUTATION AT THE HIP-JOINT
[Edinburgh Medical Journal, vol. xvii, 1871-2, p. 144.]
AT a meeting of the Medico-Chirurgical Society of Edinburgh on the 6th of
June, a communication was made by Mr. Lister to the following effect :—
Mr. President.—I have to exhibit this evening, in the first place, a case
illustrating the results of excision of the wrist for caries, performed according to
the principle and method described by myself in the Lancet several years ago!;
the principle being the removal of the entire articular apparatus of the wrist, in-
cluding all the carpal bones, together with the articular extremities of the radius
and ulna and five metacarpals, so as to place this excision in the same favourable
position as that of the elbow, while the method (fully described in the Lancet)
permits free access to the affected bones with the least possible injury to the
tendons. The young man now before you is Case 5 of those described in the
Lancet (March 25, 1865), and I may quote shortly from the account there
given.2 ‘Thomas Morris, aged twenty-one, a miner, was admitted on the 8th of
July, 1864. About six months before, when suffering from small-pox, he was
seized with inflammation in the right tibia and the left carpus, resulting in
necrosis of the former, and caries of the latter. When he came into the hospital,
the back of the wrist was swollen, and presented two sinuses, through which
a probe could be passed down to the diseased bone. The hand was extremely
feeble, and drooped when the arm was extended horizontally. It was very
painful, interfering seriously with his night’s rest, and his general health was
otherwise much deranged, his pulse being 135, and his appetite impaired, while
he was constantly bathed in perspiration.’ On the 16th of July, I removed
the parts represented in a sketch given in the Lancet, as you will see from the
copy I have brought with me. (The sketch is reproduced on p. 200.)
You observe, it includes the entire articular apparatus of the wrist. ‘A
carious cavity occupied the place of the semilunar bone, and the adjacent
part of the cuneiform was excavated. The other carpal bones, except the
trapezium, were anchylosed into one mass.’ Nearly seven years having elapsed
since the operation, we are in a good position for judging of its results. You
observe that the hand has, on the whole, a very natural appearance, but that
1 See p. 417 of this volume. 2 See p. 423 of this volume.
200 ON “ANTISEPTIC DRESSING UNDER
it presents at the dorsal aspect a transverse prominence, caused by the growth
of new bone from the divided end of the radius, which seems to have become
expanded into a socket for the reception of the ends of the metacarpal bones
which have been rounded off by ossific deposit. Thus, a new joint has been
constructed, of a form which, I may remark, I have seen in another case after
the same operation. The formation of new bone has not taken place to the
same extent from the ulna, and the hand has in an exaggerated degree the
droop to the ulnar side which it assumes in the normal condition of the limb
in a state of repose. Nevertheless, eversion and inversion of the hand can be
carried through as great an angle as usual, proving that the tendons of the
flexors and extensors of the wrist, necessarily divided in the operation, have
formed secure new attachments. Flexion and extension of the wrist, and
pronation and supination, are, you see, freely
performed, and every joint of every digit has
its normal movement, those of the knuckles
only being not quite so free as in the other
hand. You remark the perfect freedom of
the actions of the second joint of the thumb,
the extensor secundi internodii pollicis having
been left intact by placing the radial incision
in the angle between it and the indicator,
where the cicatrix is still seen. The hand has a
powerful grasp, as any of you may be satisfied
by shaking hands with him. [The patient,
before thus exhibiting his powers to the members of the Society, made a state-
ment to the effect that he was engaged in charge of a steam-engine, and found
his left hand equal to the right for all sorts of work, including wheeling a heavy
barrow, and various other actions of a laborious and complicated character. ]
This case, Mr. President, is certainly very gratifying, as an example of what
may be done in the way of saving a hand from amputation by means of excision ;
but it is still more gratifying to be able to avoid excision by early free incision,
practised antiseptically, before sinuses have formed, and followed up by anti-
septic dressing. Five cases of this kind in the adult have occurred in my practice
in the course of the last year, and useful as is the hand which you have just
seen, it is of course not equal to the perfectly natural condition that may be
retained by antiseptic management.
The next case I have to show illustrates what I believe will be found a
valuable method of treatment for certain cases of
Deformity from Contracted Cicatrix.—This young woman fell into the fire
SOME CIRCUMSTANCES OF DIFFICULTY 201
when an infant, burning the left side of the body to a frightful extent, the scar
being seen to reach from the upper part of the neck to the lower part of the
forearm, and laterally from near the spine to the mamma, the mammilla having
been destroyed. The healing of the huge granulating sore, and the subsequent
shrinking of the cicatricial tissue, led to the formation of a web of several inches
in length, constituting an extension of the posterior fold of the axilla down-
wards, and binding the arm pretty closely to the side. We all know how
unsatisfactory the treatment of such cases commonly is. The web, if divided
with the knife, becomes reproduced by the coalescence and contraction of the
granulations, and the condition of the patient is too often little, if at all, better
than it was originally. In the present instance the tendency to coalescence
of the granulations has been counteracted by a method which I employed first
several years ago in a case of webbed fingers, viz. bringing the elastic traction
of india-rubber to bear upon the angle of the wound made by cutting through
the web. At the same time this plan of treatment has been greatly assisted,
both in the earlier and later stages of the case, by antiseptic management.
The irritation of the cut surface by putrefaction being avoided during the first
few days after the operation, inflammation was entirely prevented, and thus
we were able, even from the first, to use a degree of freedom with the limb
in raising it from the side, which would have been otherwise intolerable. It
happens that I have now under my care in the infirmary another similar case,
operated on only two days ago, when a web of great length, and involving the
whole breadth of the axilla, was freely divided; and my friend Dr. Holmer,
of Copenhagen, who is here to-night, and who saw the patient dressed this
morning, can bear me out when I say that the skin around the very extensive
raw surface was perfectly free from redness or tenderness ; while the young man
was able to get up and move about almost as if nothing had been done to him.
The advantages of antiseptic treatment have been equally great in the further
progress of the case before you, for when sores are efficiently protected both
from the irritation of putrefaction and from that of the antiseptic, they heal
under circumstances inconsistent with cicatrization under water dressing ; and
the mechanical irritation involved in the varied traction to which the sore
has been here exposed, would probably have prevented healing altogether had
the ordinary application been made. I have thought it best to exhibit the
patient before healing is complete, in order that you may see the treatment
in progress ; and as the mode of dressing presents several features of interest,
I will venture to trespass upon your time by performing it before you. The
retaining bandage being now removed, you see the rod of india-rubber [a rod
of vulcanized india-rubber about as thick as the little finger] which exerts its
LISTER Il I
202 ON ANTISEPTIC DRESSING UNDER
traction upon the angle of the wound in the axilla. Its ends are attached to
pieces of bandage which are tied in a half-knot over the top of the shoulder
and then secured to the ends of a padded handkerchief passing under the other
armpit, the shoulder being protected from the pressure of the knots by a shield
of thick gutta-percha moulded to it. It is three days since the dressing was
last changed ; yet it remains perfectly free from putrefactive smell, implying
that the antiseptic gauze, which is the essential material of the dressing,? has
answered its purpose well; and the axilla is a situation that illustrates the
perfect manner in which it adapts itself to any irregularities of surface. Between
the gauze and the healing sore is interposed the oiled-silk ‘ protective’, to
exclude the irritating influence of the antiseptic ; and, in this particular case,
the value of the protective is especially marked. For, if it were omitted, not
only would the progress of cicatrization be arrested, but, as we have found by
experience, the newly formed cicatrix being weak from the traction to which
it is subjected by the old scar around, becomes excoriated under the influence
of the carbolic acid furnished by the gauze. Under the protective, on the other
hand, healing proceeds securely and uninterruptedly.
In the earlier stages of the case the protective rendered further service,
because, being applied next to the raw surface, it prevented the possibility of
the granulations coalescing below the caoutchouc band, and enclosing it in
a tube of granulation structure.
You observe how efficacious the india-rubber band has proved. According
to the tightness with which it is tied up, the pressure which it exerts upon the
angle of the wound can be precisely regulated, so as to cause continuous ulcera-
tion, if desirable; and thus, so far from the angle of the wound becoming
filled up by granulations, the original incision has been, as it were, extended
by the ulcerating process considerably beyond its original limits, yet without
any pain to the patient ; and you can observe the fibres of the pectoralis major
and latissimus dorsi lying bare in the groove which the caoutchouc rod occupied.
Meanwhile cicatrization has advanced both on the chest and on the arm almost
up to the margins of the groove. The india-rubber rod, as soon as it is removed,
is well washed with watery solution of carbolic acid ; and, as caoutchouc imbibes
the acid, it becomes itself antiseptic for the time being. The sore having been
also washed with the lotion {a solution of one part of the acid in two hundred
parts of water is sufficiently strong for the purpose], I now apply a piece of
protective dipped in the same liquid, and outside this the rod of india-rubber,
’ This gauze contains carbolic acid stored in insoluble resin among the fibres, with the addition
of paraffin to avoid undue adhesiveness, in the proportions of one part of carbolic acid, five parts of
resin, and seven parts of paraffin.
SOME CIRCUMSTANCES OF DIFFICULTY 203
and then a piece of well-overlapping antiseptic gauze, bandaged securely both
to the arm and to the chest.
The gutta-percha shield for the top of the shoulder is padded with the
gauze ; and this illustrates another valuable use of that material. Supposing
that the padding were of an ordinary kind, such as cotton-wool, putrefaction
could hardly fail to take place in the sore. For the edge of the protective comes
up to the immediate vicinity of the shield, and the discharge escaping from
beneath it would soak into the padding and putrefy there, and the fermentation
would be communicated to the fluid beneath the protective ; since this layer,
while it protects the sore from the irritation of the antiseptic, necessarily involves
liability of any organic material that lies beneath it to putrefaction on access
of the ferment. But by having the padding of the shield itself antiseptic this
difficulty is overcome, the gauze of the axilla and that of the shield coming
in contact with each other; and we have not had putrefaction occur on any
single occasion since the operation. The advantages of this material are still
further exemplified in this case by its use in the form of bandage, every turn of
which, instead of affording a nidus for putrefaction, increases the antiseptic
efficacy of the whole dressing.
It yet remains to show you what the patient can do in the way of raising
the arm. At the time of the operation I did not get it quite up to the horizontal
level. In the course of a few days it could be brought up to that level. Then
her ambition came to be to reach up with her finger-tips to the handle of a small
cupboard in the ward, fixed at some distance above the floor. Afterwards,
stretching a little higher day by day, she was at length able to reach to the top
of the cupboard, about nine inches higher ; and now, within the last few days,
by means of this species of gymnastic exercise, she has succeeded in getting
her knuckles even higher than the top; and you see at present that she can
raise both hands well above the head, and touch nearly as high a point on the
wall with the one as with the other. Thus, instead of the usual course after
such operations—namely, the web gradually forming again, and what was
gained at the operation being ultimately lost—we have here made constant
progress in advance of what the operation effected, and all this without the
use of any means of extension, or any restraint upon the natural actions and
usefulness of the limb. There can therefore, I conceive, be no doubt that, by
persevering a little longer with the same system, we shall attain all that can be
desired.
The next case I have to bring before you is an instance of recovery after
primary amputation at the hip-joint, a thing by no means of common occurrence.
The injury that necessitated the operation in the boy now before you (five
Pp ?
204 ON ANTISEPTIC DRESSING UNDER
years of age) was of extreme gravity. The little fellow had been endeavouring
to climb up into a luggage-truck, when his right leg became entangled in one
of the wheels, and frightfully mangled. The hamstrings and popliteal vessels
were torn through, the knee-joint opened posteriorly, the femur fractured in
the wound, and the soft parts of the thigh contused to so high a level, that
I was obliged, as you observe, to make the anterior flap shorter than usual,
and eke it out by extending the posterior flap; and, in spite of this, a small
portion of the anterior flap lost its vitality from being implicated in the con-
tusion. Now, there can be no doubt that, under such circumstances, the
avoidance of putrefaction in the large wound was a most important condition
of his recovery. Considering the state he was in, I believe that, if we had not
succeeded in this respect, he would not have been alive before us this evening ;
and my reason for bringing him here is, that he affords another striking
illustration of the advantages of our present mode of antiseptic dressing.
Of all incised wounds, those resulting from amputation have been the
most difficult to manage antiseptically ; and of all stumps, that at the hip-
joint is the worst to deal with. When a stump has considerable length, we
have for some time past managed quite satisfactorily by having it enveloped
in about eight layers of the gauze, a piece of impermeable tissue, such as thin
macintosh cloth,’ being placed beneath the outer layer to compel the discharge
to travel throughout the extent of the antiseptic tube formed by the dressing,
before reaching the external air. The essential condition of free overlapping
of the surrounding skin is thus complied with, while the use of a spray of carbolic
acid lotion avoids any chance of the entrance of septic mischief during the
changing of the dressing. But in a case like this, such an arrangement is of
course impossible ; and we had two special difficulties to contend with. One
was the vicinity of the inner angle of the wound to sources of putrefaction in
the perineum. This was overcome partly by stitching up the wound very
closely at the inner side, and having the ‘ drain’ (of lint soaked with carbolized
oil) projecting towards the outer aspect, so that discharge might be as small
as possible towards the perineum. At the same time, the gauze, from its
absorbent as well as antiseptic property, was of the utmost value, and, being
folded of double thickness at the perineal side, answered the purpose completely ;
while in this case, as in the last you saw, the antiseptic quality of the bandage
was of peculiar value, every turn round the perineum adding to the antiseptic
security. And I may notice here another incidental advantage of this bandage,
namely, that the slight adhesiveness which it possesses makes it cling to the
part to which it is applied, and prevents the turns from slipping, as those of
* This tissue is known by the caoutchouc manufacturers under the name of ‘ hat-lining ’.
SOME CIRCUMSTANCES OF DIFFICULTY 205
a calico bandage are so apt to do. I should add that, during the changing of
the dressings, two of Richardson’s spray-producers, worked simultaneously by
two dressers so that each commanded half of the large wound, proved adequate
to the purpose.
The other great difficulty was the vicinity of the wound to the bed. Had
the discharges been permitted to soak into the bedding, they would have soon
putrefied there after losing the volatile antiseptic ; and the products of putre-
faction, soaking back into the dressing, would in all probability have neutralized
its antiseptic virtue, and the fermentation would have penetrated to the wound.
This danger was averted in the simple way you see here illustrated—by having
the gluteal region repose on a layer of folded gauze lying on a piece of macintosh
cloth. In this manner the bed in which he lay was rendered itself antiseptic
at the part with which the wound was concerned, and putrefaction was avoided
from first to last.
While speaking of the advantages of the gauze, there is one other to which
I cannot forbear alluding. If you apply this mass of it, consisting of thirty-two
layers, closely to the face, you find you can breathe freely through it, as through
a respirator. Hence, Sir, one great advantage of this dressing will be, that it
will deprive those who discuss the antiseptic treatment of all excuse for speaking
of it as operating by ‘ excluding the air’. We do not exclude the gases of the
atmosphere at all, but adopt efficient means to destroy the energy of its floating
ferments.
ON RECENT IMPROVEMENTS IN THE DETAILS
OF ANTISEPTIC SURGERY
[Lancet, 1875, vol: 4, pp. 365, 401, 434, 468, 603, 717, 787.|
SINCE the delivery of my address at the Plymouth meeting of the British
Medical Association in 1871,' various improvements have suggested themselves
in the means of carrying out the antiseptic principle. Some of these improve-
ments have been the results of more extended experience with the materials
previously in use, while others have consisted in the employment of new anti-
septic substances.
With regard to materials previously in use, I wish in the first place to correct
what I fear was a mistake made in the Address as to the strength of the watery
solution of carbolic acid to be used for the sponges during operations, and for
the cloths employed for washing and guarding wounds in changing dressings.
Anxious to reduce the strength of the solution as much as possible, in order to
avoid needless irritation of the tissues by the acid and at the same time to pro-
mote the comfort of the operator, I had thought myself justified by experience
in recommending a lotion as weak as 1 to 100. I have since had reason to
believe that in so doing I had gone beyond the limits of safety ; so that I have
returned to the 1 to 40 lotion for the purposes referred to, while the saturated
watery solution (I to 20) is still employed for purifying the epidermis of a part
about to be operated on, for cleansing dirty instruments and sponges, and also
for washing accidental wounds, so as to destroy once for all any septic organisms
that may have been introduced into them.
A solution of carbolic acid of the strength of r to 40 is that which I would
advise for providing an antiseptic atmosphere in the form of spray when the
particles of the liquid are dispersed by means of air impelled by hand-bellows or
a condensing pump. But I have of late found it more convenient to use high-
pressure steam as the motive power, on the principle of Siegle’s steam inhaler,
* See p. 172 of this volume.
* For cases of compound fracture seen for the first time several hours after the accident, I have
of late used a still stronger antiseptic in the form of one part of carbolic acid dissolved in five parts of
spirit of wine, introduced into the recesses of the wound by means of a gum-elastic catheter connected
with a syringe by a piece of caoutchouc tube. In this way the antiseptic is made to penetrate the
coagula in the various parts of the wound more effectually than it could be by forcing it in through the
external orifice, while at the same time we avoid the needless disturbance which this procedure may
entail in consequence of the irritating liquid being driven for a greater or less distance through the
cellular interstices of uninjured parts.
ON RECENT IMPROVEMENTS IN ANTISEPTIC SURGERY 207
the apparatus, modified to adapt it for our purpose, being both self-acting and
self-directing, so as to dispense with the services of an assistant. But in this
case the water of the condensed steam dilutes the solution with which it becomes
blended in forming the spray, so that it is needful to use a larger proportion of
the acid. Inthe machines hitherto constructed, one part of water is consumed
by ebullition for three parts of solution sucked up to mingle with it, and thus
I to 30 is the proper proportion of the acid in order to form a 1 to 40 spray.
As a dressing for excluding putrefactive iermentation from wounds, the
antiseptic gauze, which contains in its fibres carbolic acid stored up in common
resin, which is of course insoluble in the discharges and holds the acid with
great tenacity, has continued to prove thoroughly trustworthy if properly
“used; so that, provided always we have the essential condition of a sufficient
space of skin in every direction from the wound for the gauze to cover, we may
be quite sure that a wound left free from the causes of putrefaction when dressed
will be found similarly aseptic when we change the dressing—a fact which no
one, perhaps, who has not gone through the labours and anxieties which have
fallen to my lot in striving after its attainment can fully appreciate. Under
ordinary circumstances we still use the gauze in eight layers, with a sheet of
some trustworthy impermeable tissue placed beneath the outermost layer to
prevent the discharge from soaking directly through the dressing, for if it did
so a copious effusion might wash out the antiseptic from the part immediately
over the wound and putrefy within twenty-four hours. The most durable
and therefore most reliable material for the purpose, consistent with the requisite
lightness, is a fine cotton cloth with a thin layer of caoutchouc on one side,
known in the shops as hat-lining or thinnest macintosh. This, if of good
quality, may be used for the same case for weeks together. But, unless parti-
cular care is taken with its manufacture, the caoutchouc layer tends to adhere
in the folds which it acquires from the various altered positions of the dressing,
and portions of it may then be torn off when the folds are straightened out,
thus destroying the essential property of impermeability ; and if the macintosh
be still used in that condition, entire failure of the dressing may result.
I have just now under my care a case in which I opened antiseptically
an abscess connected with disease of the hip-joint, where all went on typically
for a considerable time, the discharge being merely serous, and so diminished
1 Different steam spray-producers may differ in this respect in consequence of slight variations in
the relative sizes of the orifices for emitting the steam and lotion respectively. It is therefore right
that in every case the actual proportion between the steam and solution consumed should be ascertained
by the maker, and stated to the surgeon. Inabsence of such information the surgeon can readily settle
the point for himself by working the spray for a while with given quantities of water in the boiler and
lotion in the bottle, and then measuring the amount remaining in each vessel.
208 ON RECENT IMPROVEMENTS IN THE
in quantity that the dressing was left unchanged for several days together,
when, in consequence of imperfection of the macintosh, the discharge was
observed to have soaked directly through the dressing opposite the wound,
and, apparently as a result of this, putrefaction had crept in, which soon led to
profuse suppuration and hectic, necessitating excision of the hip-joint.
It is therefore needful to have this material specially prepared to obviate
the tendency to adhesiveness. And in all cases a second piece of the macintosh
should be at hand, so that when one piece is observed to become impaired by
wearing, the other may be substituted for it.
The macintosh having no antiseptic property except mechanically by its
impermeability, but, on the contrary, being, like other indifferent materials,
covered more or less with septic matter, it is necessary, when the dressing is ©
a compound one, or, in other words, consists of more pieces than one, that the
macintosh be well covered in at the place of junction of the two pieces, for if
it were allowed to project uncovered in the vicinity of the wound, it might
communicate septic mischief.
As an example of a compound dressing may be given one which, from the
frequency of the cases requiring it, is the most important of all—viz. that used
after removing the mamma. It consists of two pieces of folded gauze and
macintosh, a posterior and an anterior one. The posterior portion is about
half a yard square, and reaches vertically from above the acromion to a little
below the elbow, and transversely from the spine to the arm, which it envelops
as it lies beside the chest, thus forming a complete antiseptic basis for the region
of the shoulder, and effectually guarding against what would otherwise be most
difficult to avoid, the extension of putrefaction from the bedding through the
axilla into the outer angle of the wound. The anterior dressing, though not so
broad as the posterior one, is of about equal length, so that when applied to
the chest it may reach from some inches beyond the anterior angle of the wound
to the posterior dressing, which it joins below the back of the axilla ; and here
it is that it is needful to have the macintosh well covered in among the folds
of the gauze. The infra-axillary region being the part where the chief discharge
occurs, it is of the utmost importance that the outer part of the anterior dressing
be maintained well in apposition with the skin, and this is ensured by stuffing
a substantial mass of gauze irregularly packed together between the patient’s
side covered by the dressing and the lower part of the arm. This additional
mass of gauze has the further advantages that it serves as a supplementary
antiseptic material to absorb the discharge, and that it prevents the arm from
being closely pressed to the side—a position which, besides being irksome to
the patient, would entail the serious evil of interference with free drainage from
DETAILS OF ANTISEPTIC SURGERY 209
the outer angle of the wound. In order to prevent the occurrence of bed-sore
over the external condyle, a wisp of gauze, twisted and rolled together in the
form of a ring, is placed beneath the elbow so as to receive the bony prominence
in its hollow. The whole dressing is secured in position by suitable turns of
a gauze bandage, which is extremely convenient on account of its lightness,
and also from the circumstance that the slight adhesiveness of the material with
which it is charged checks the tendency of one turn to slip upon another, so
that it is more secure than a common cotton roller, besides the advantage that it
increases the antiseptic efficacy of the dressing. But, on account of its loose
texture, it cannot be properly fixed by ordinary pins, which would be liable
to shift their position in it. Those called safety-pins, made on the principle
of a brooch, should therefore always be employed ; for there are cases in which
the slipping of a single pin might, by allowing the dressing to shift its place,
endanger the life of a patient.
There is another point in the use of the gauze to which I wish to direct
special attention. The very quality which makes this material so valuable as
a permanent antiseptic dressing, and renders it both mild and persistent in its
effects—namely, the tenacity with which the resin in its fibres holds the carbolic
acid—may become a source of serious danger at the time of application. [or at
ordinary temperatures of the air the antiseptic is given off by the gauze in such
extremely small amount that particles of dust falling upon it cannot be expected
to be deprived of septic energy by contact with it, as they are by a I to 40 watery
solution. Hence, if a piece of gauze is applied dry to a wound communicating
with a cavity containing blood, serum, or pus, as ina compound fracture, a stump
after amputation, or an abscess, portions of septic material on the surface of
the gauze may become mingled with the discharge at the outlet, and, thus
shielded from the subsequent action of the carbolic acid, may spread fermenta-
tion into the interior. Had it not been for the use of the spray, which plays
on the under surface of the gauze when applied, I cannot doubt that this cause
would often have led to failure. But considering the very short time during which
the spray often acts on the gauze, it is plain that 1t would be imprudent to trust
to it for purifying the surface. This, however, can be done with the utmost
readiness, either by wetting with the 1 to 4o lotion the part of the gauze dressing
which is to go next to the wound, or, what is commonly more convenient, by
applying to the wound itself a separate piece of gauze soaked in the lotion,
and over this the dry gauze in its eight layers. When the discharge is slight,
a single layer of this moist loose gauze is sufficient, but if it is copious the wetter
portion must be substantial.
In situations where there is not as much extent of skin for the gauze to
210 ON RECENT IMPROVEMENTS IN THE
overlap as is desirable—for example, in the vicinity of the pubes, as after
herniotomy—the deficiency of surface of the dressing may be compensated by
using the gauze in a thicker mass; say in sixteen or thirty-two layers. By
this means such wounds may be securely kept from putrefaction, which with
only eight layers it might be impossible to avoid.
Details like these, tedious as they are to describe, are of course very easy of
execution, and attention to them will, I doubt not, be rewarded, in the hands
of others as it has been in my own, by a constancy of results which leaves little
if anything to be desired.
With regard to the times of changing the dressing, it is, as a general rule,
prudent to inspect the wound the day after its infliction, whether it be accidental
or the result of operation. But during the subsequent progress of the case
the gauze may be left undisturbed for periods varying from two days to a week,
in proportion to the diminution of effusion; the general rule being that the
dressing should be changed on any day on which the discharge is observed
to have extended beyond the edge of the folded gauze so as to make a stain
upon the clothes or bedding.
Invaluable as the gauze is, I greatly regret to find that its use is restricted
by the high price at which it is often sold. I will, therefore, now describe the
manner in which it has been prepared for a long time past at the Royal Infirmary
of Edinburgh, with the effect of reducing by more than half the wholesale price
previously paid by the institution. First I may remark that the chief element
in the cost is the cotton cloth, the expense of the materials with which it is
charged being less than a farthing per square yard of the gauze. It is therefore
of great importance to obtain the muslin as cheap as possible from the manu-
facturer, and a little saving is effected by having it unbleached. The materials
used for charging the gauze are—i part of crystallized carbolic acid, 5 parts
of common resin, and 7 parts of solid paraffin; the last ingredient being used
for the purpose of preventing undue adhesiveness. Paraffin has this advantage
compared with any other substance of similar consistence with which I am
acquainted, that it does not blend at all with carbolic acid in the cold, and
therefore simply dilutes the mixture of acid and resin, without interfering in
the least with the tenacity with which the resin holds the acid. If, for example,
we compare it with a substance like spermaceti, we find that a mixture of I part
of the acid with 5 parts of resin and 5 parts of spermaceti is really much more
pungent to the tongue than the 5 parts of resin and 1 of acid alone. For
although the former mixture contains only half the quantity of the acid, yet
the spermaceti, blending with the acid like the resin but holding it less firmly,
takes the acid from the mixture and gives it up to surrounding objects. Such
DETAIES OF ANTISEPTIC SURGERY 211
a mixture of resin, spermaceti, and carbolic acid, therefore, though admirable
in consistence, would be both less mild and less permanent in action than the
resin and acid alone. The addition of paraffin, on the other hand, has no other
effect on the mixture than to render it somewhat more mild. It seems needful
to point out this circumstance, because, from want of knowledge of it, modifica-
tions of the gauze have been suggested in which the paraffin has been replaced
by other materials, which cannot fail to be disadvantageous.
In order to charge the gauze, the paraffin and resin are first melted together
in a water bath, after which the acid is added and blended by stirring. The
object now is to diffuse this melted mixture equably through the cotton cloth,
and for this purpose two things are requisite—viz. that the cotton be at a higher
temperature than the melting-point of the mixture, and that it be subjected
to moderate pressure after receiving it. The cotton cloth, a yard wide, is cut
into six-yard lengths, and these, having been folded so as to be half a yard
square, are placed in a dry hot chamber formed of two tin boxes placed one
within the other, with an interval to receive water, which is kept boiling by
fire or gas beneath, the upper edges of the boxes being connected and provided
with an exit-pipe for the steam. There is also a glass tube arranged as a gauge
of the amount of the water, and the chamber has a properly fitting lid. The
bottom of the chamber is strengthened with an iron plate, to enable it to bear
the weight used for compressing the gauze when charged. This is a piece of
wood, about two inches thick, nearly fitting the chamber, covered with sheet-
lead, so as to make it about as heavy as a man can lift by means of two handles
in the upper surface. The weight is heated along with the cotton, and is put
first into the chamber so as to leave the cotton loose for the penetration of the
heat, which occupies two or three hours. The cotton, when heated, is taken
out of the chamber along with the weight, and placed in a wooden box, to protect
it from the cold. (It would be better to have a second hot chamber for this
purpose, since in cold weather the cotton is apt to be too much cooled in spite
of the protection of the wooden box.) The heated gauze is then at once charged
with the melted mixture of carbolic acid, resin, and paraffin, in quantity equal
to the weight of the cotton fabric (or slightly less), and, in order to diffuse the
liquid as equably as possible, it is sprinkled over the gauze by means of a syringe
with a number of minute perforations in its extremity, the body of the syringe
and the piston-rod having each a wooden handle to protect the hands of the
workman from the heat. The syringe is constructed to hold half the quantity
of the mixture required for charging one piece of cloth. One folded piece
being placed at the bottom of the hot chamber, its upper half is raised and
turned aside, and one syringeful is sprinkled over the lower half. The upper
22 ON RECENT IMPROVEMENTS IN THE
half is then put back into position and another syringeful thrown on. The
same process is repeated with all the other pieces of gauze, after which the
weight is put into the chamber to compress the charged cotton, and the lid
applied. An hour or two are then allowed to elapse to permit the complete
diffusion of the liquid, when the material is fit for use.
The apparatus above described can be constructed by a common tinman
for about {10; and it is estimated that the entire cost of the gauze to the
Edinburgh Infirmary, including the price of materials and manufacture, is
somewhat less than 2d. per square yard. For hospital purposes this expense
is further reduced by the fact that the gauze, after being used for dressing a case,
can be entirely cleansed of the substances with which it was charged by washing
in boiling water, care being taken to press it well in the hot water with a suitable
wooden implement. The cotton cloth is then even better adapted for the
purpose than it originally was, having lost the slight rigidity caused by the
starch or gum used to stiffen the threads before weaving. Thus the same piece
of cotton may be used over and over again, with saving to the institution of
the chief cost of the material, which, as before said, is that of the cotton. Prac-
tically, however, it is only larger dressings which will repay the trouble of washing
and arranging in proper masses for recharging.
Solution of carbolic acid in the fixed oils, which, as regards the tenacity
with which they hold the acid, occupy an intermediate place between the watery
solutions and the resinous mixture in the gauze, has been for the most part
superseded by these latter; a watery solution being more efficient as well as
more cleanly for a detergent lotion, while the resinous mixture is more mild
and more persistent, and therefore better adapted for a permanent dressing.
There are, however, some circumstances in which the oily solutions are valuable.
For lubricating instruments introduced into the bladder, such as catheters,
bougies, sounds, or lithotrites, I have for some time past used a solution of one
part of carbolic acid in twenty parts of olive oil’—-a proportion which, while
unirritating to the urethra, is trustworthy as an antiseptic; and there can be
no doubt that the avoidance of putrefactive fermentation within the bladder
is in many cases a matter of vital importance. In using a catheter, the interior
of which cannot be kept clean, but must have more or less of foreign material
encrusted upon it, some of which might by chance enter the bladder from
regurgitation, the instrument should either be kept for several minutes with
the carbolic oil within it before it is passed, or, what is more efficient and saves
* The practice of using carbolized oil for lubricating instruments introduced into the bladder was
first suggested, so far as I am aware, by Professor Rolleston, in his address on Physiology delivered
at the Oxford meeting of the British Medical Association. (See British Medical Journal, August 15, 1868.)
DETAILS OF ANTISEPTIC SURGERY 213
time, it may be washed out with the 1 to 20 watery solution before being smeared
with the oil. Washing urethral instruments with such a lotion will probably
have the further important advantage of securing us against the conveyance
of specific virus from one patient to another by their means. For a protracted
experimental investigation into the subject of putrefaction and other fermentative
changes having proved to me the perfect efficiency of the 1 to 20 watery solution
of carbolic acid in destroying minute organisms of a fungoid or bacteric nature,
I feel that we can hardly be wrong in assuming its destructive effect upon the
viruses alluded to, which, though not proved to be organisms, analogy leads
us to regard as in all probability of such a nature. If this be so, the use of such
a lotion and lubricating oil for specula and other articles used in female com-
plaints will prevent in the other sex the lamentable results which have now
and then occurred from instrumental infection.
Cases from time to time arise in which it is desirable to have an antiseptic
in constant active operation on the interior of a wound, necessitating the frequent
renewal of the dressing ; and for this purpose a solution of carbolic acid in about
ten parts of olive oil answers well.’ As an example of its use in this way, I may
mention a practice which I have adopted of late years in caries limited to the
middle or anterior part of the tarsus and accompanied by sinuses. Cutting
right across the soft parts of the dorsum of the foot, including the tendons,
vessels, and nerve, I open the tarsus completely from side to side at the diseased
part, when, the foot being bent upon the sole as upon a hinge, the carious portions
are exposed with perfect freedom for inspection and operation, and all bones
or portions of bones that appear suspicious are removed, the procedure being
rendered much more precise and satisfactory by the bloodless method of operat-
ing which I have for many years pursued—viz. emptying the limb of blood by
raising the foot to the utmost for a few minutes, and then applying a tourniquet
as rapidly as possible and so tightly as to prevent any circulation in it The
vessels having been secured, it remains to dress the wound. If this were done
in such a way as to permit unchecked putrefaction in it, there would be great
risk of serious disturbance from the extension of putrefactive suppuration into
the tarsal joints opened in the operation. On the other hand, as the sinuses
communicating with the wound already contain putrescent materials, it would
be useless to operate under the spray and apply an external gauze dressing.
* Linseed oil is objectionable from the permanent staining it produces in linen. Boiled linseed oil
is, indeed, far better than any other oil for mixing with whitening and carbolic acid to form the antiseptic
paste or putty, which has long since been superseded by the gauze, but which on an emergency, in
absence of the gauze, might still be used with advantage in some cases.
* Since Professor Esmarch has published his method, I have substituted an india-rubber tube for
the tourniquet with advantage.
214 ON RECENT IMPROVEMENTS IN THE
What is needed is something that shall prevent the putrefaction from spreading
from the points where it may exist to the rest of the wound. This object is
attained by first washing the cut surface with the solution of chloride of zinc,
40 grs. to I oz. of water—a practice of the utmost value in all cases where, in
consequence of the presence of sinuses or the situation of the part, as the mouth
or perineum, it is impossible to exclude causes of putrefaction from the wound,
When sinuses are present, I formerly advised their injection with solution
of the chloride by means of a syringe before the commencement of the operation.
But though this is undoubtedly the most efficient mode of introducing the
liquid into the recesses of the sinuses, I have found that the force with which
the solution is driven in by the syringe may cause it to burst through the pyogenic
membrane of the sinuses and become effused into the cellular tissue. This
accident, in two instances (one of caries of the wrist and one of amputation
through the condyles of the femur) led to extensive loss of vitality of the integu-
ment, and hence for the last three years I have contented myself with injecting
the sinuses at the conclusion of the operation, when, the sinuses being freely
open at the wound, the risk referred to no longer exists.
Chloride of zinc, I may remind the reader, has this remarkable peculiarity
among all antiseptics that I have tried, that a single application of it to a recent
wound in a solution of the strength above mentioned, though it produces no
visible slough, yet prevents the occurrence of putrefaction in the cut surface for
days together, in spite of the access of septic material ;+ and if the discharges
have opportunity to flow freely away, as after the removal of a tumour of one
of the jaws or a portion of the tongue, there may be absolutely no odour from
first to last, the divided textures being thus guarded from the bad effects of
putrefaction during the dangerous period before they have been covered by
the protecting layer of granulations.
But in the wound of the foot which we are considering, if any permanent
dressings were employed, the blood and serum effused in the early periods of
the case, and accumulating more or less in the interior, would not be prevented
from putrefying by the chloride on the cut surface. And it is only in rare cases
that the injection of the sinuses with the chloride has the effect of eradicating
all putrefaction from them. This is a thing to be aimed at, but hardly expected.
In order, therefore, to avoid the extension of putrefaction from any septic point
in the wound, the antiseptic dressing must be frequently changed; and this
is conveniently done with pieces of lint dipped in the oily solution of carbolic
acid (1 to 10), the oil preventing the lint from sticking in the wound, so that it
* For the introduction of this invaluable antiseptic into surgical practice the profession is indebted
to Mr. Campbell De Morgan, of the Middlesex Hospital, London.
DETAILS OF ANTISEPTIC SURGERY 215
can be readily removed. In order to admit of the free application of this dressing
to all parts of the cut surface, the wound is made to gape freely by depressing
the toes along with the foot-piece of the M‘Intyre splint on which the limb
rests. The oiled lint is renewed every three hours day and night during the
first twenty-four hours, and after this the interval is gradually increased as
discharge diminishes, till after three or four days one dressing per diem is sufficient.
The free exposure of the wound has this further important advantage, that
it permits the surgeon to examine the surface with the finger from time to
time in order to ascertain when the bones are entirely covered with soft granu-
lations ; for then and not till then can he be sure that the bones are perfectly
sound, and as soon as this is the case the foot-piece is adjusted at right angles
with the leg, so as to permit the granulating surfaces to coalesce and the wound
to heal. In all the five cases in which I have hitherto had occasion to employ
this treatment, the immediate object was completely attained, the foot remaining
quite free from inflammation, and the constitution without febrile disturbance.
Two of the cases are still under treatment, not yet completely cicatrized. Of
the other three feet operated on in this way, two are useful and strong, though
more or less shortened. The other, after being a perfectly serviceable foot
for several months, became the subject of relapse, requiring amputation at the
ankle. The practice was suggested to me by the remarkably satisfactory results
of antiseptic treatment in a case of wound by a circular saw which divided the
soft parts completely at the instep, laying the ankle-joint freely open. The
patient not only recovered with a freely movable ankle-joint, but, except a line
of cicatrix across the instep, there was nothing abnormal in either the appearance
or actions of the foot. And it is somewhat remarkable that, in the cases of
disease, where the wound has been left gaping for weeks, not only has the power
of extension of the toes been restored, but sensation has been recovered in the
parts supplied by the divided nerve.
As another example of the usefulness of the oiled lint may be mentioned
abscess beside the rectum, where the vicinity of the anus renders a permanent
gauze dressing inapplicable. The skin having been washed with 1 to 20 watery
solution of carbolic acid, the abscess is opened under the spray where it points,
and a pad of lint soaked with 1 to 10 carbolic oil! is applied and retained by
a T bandage, and changed every five or six hours. Before defecation, the patient
draws the bandage and pad towards the side where the wound is, so as to keep
the latter covered while exposing the anal outlet, which is carefully cleansed
with a piece of lint dipped in the antiseptic oil before the pad is readjusted.
1 Lord Lister afterwards substituted glycerine for oil as the vehicle for the carbolic acid in the
dressing ; the anus being cleansed, on exposure, with the watery solution.
216 ON RECENT IMPROVEMENTS IN THE
The oil, penetrating among the folds of the skin, is more efficient for this situation
than the gauze would be, even were it frequently changed. After two or three
days have passed, the strength of the oil may be reduced to I to 20, if the
stronger proportion causes irritation. I have treated several cases in this way
both in hospital and in private practice, and in every instance the occurrence
of fistula has been avoided, although in some of them it was ascertained, by
digital examination of the rectum before opening the abscess, that pus was
present in the submucous tissue—a state of things which, I believe, inevitably
leads to fistula if the abscess is treated in the ordinary way. Of course
scrupulous care on the part of the patient is essential to success, but this
I have not found wanting, even in hospital cases, when it is clearly explained
that fistula will be prevented by the requisite pains.
It is an interesting fact, pathologically, that the progress has been equally
satisfactory when the pus has been fetid on evacuation as when it was odourless,
the discharge being a mere serous oozing after the escape of the original contents.
This seems to imply that the cause of the fetor was not any organic (bacteric)
ferment, but a peculiarity in the action of the part. For had septic organisms
been present before the abscess was opened, they would have continued to pro-
pagate in it in spite of the antiseptic treatment ; and the result would have been
the same as under poultice or water dressing, or, what comes to the same thing,
under an antiseptic dressing carelessly employed. For itis hardly needful to point
out that neither the spray nor the carbolic oil applied externally, nor the oiled lint
inserted in the outlet to serve as a drain, could correct putrefactive fermentation
once established in the abscess cavity. Here, as in the antiseptic treatment
generally, the means used are calculated to prevent, not to correct, putrefaction.
In the case of abscess beside the rectum a bit of lint soaked with carbolic
oil is used for a drain, simply because in this situation it is not easy to keep
in position a caoutchouc drainage-tube, which, under ordinary circumstances,
is greatly to be preferred, since it does not at all obstruct the flow of discharge,
and may be carried to any depth that is desired, and can be removed and reintro-
duced without difficulty. Hence a drainage-tube of comparatively small size
introduced through a mere puncture in the skin, or through a small interval
between stitches, is more efficient than a free incision or a widely gaping wound
without the use of a tube. The tubes should vary in size in proportion to the
quantity of discharge anticipated, from the thickness of a crow-quill to that
of the little finger, and the holes in them should have a diameter about half
that of the tube. The outer end of the tube should be on a level with the skin,
and it is conveniently maintained in this position by means of two pieces of
silk passed with a needle through two opposite points of the edge of the tube,
DETAILS OF ANTISEPTIC SURGERY 217
the ends of each thread being knotted at a distance of one or two inches from
the tube. These knotted threads being placed straight upon the skin, one at
each side, the knots exert friction upon the dressing bound down upon them,
and prevent the tube from being pushed in, while the dressing itself keeps it
from protruding, so that the orifice lies flush with the integument. When the
tube has to be placed obliquely, its outer end must be cut obliquely in proportion,
as shown in the accompanying sketch, otherwise it is apt to become partially
buried and blocked up.
Another cause may lead to partial obstruction in chronic cases, such as
spinal abscess—viz. the projection of fungoid masses of granulations through
the holes in the tube so as to interfere with its calibre, and at the same time
cause difficulty in extracting and reintroducing it. But this inconvenience is
got over by having the holes restricted to the vicinity of the deeper end of the
tube : for it seems to be chiefly at and near the integument that the granulations
have this tendency to fungate ; and in cases of this kind it is only at the deeper
part of the tube that holes are required.
In recent wounds I used to think it needful to take out the tubes on the
day after operation or accident to clear them of clotted blood. But I find this
is wholly unnecessary, the shrinking of the clot apparently preventing it from
interfering with the exit of discharge, so that a tube introduced at the time
of an operation may be left in for three or four days, by which time the tissues
around it will have been consolidated by organizing blood or lymph into a smooth
channel, into which the tube can be readily reinserted, which is by no means
always the case if it is taken out the day after operation.
In large and deep wounds, where very free drainage is required, it is con-
venient, instead of using one tube of very large calibre, to insert several of smaller
size side by side. These, while quite as efficient as a single large one, do not
separate the edges of the wound so much, and they can be afterwards withdrawn
one after another as the discharge becomes reduced.
LISTER IL QO
218 ON RECENT IMPROVEMENTS IN THE
It is impossible to exaggerate the importance of drainage-tubes. In
abscesses they must be employed till the cavity is completely closed; and in
wounds not only are they invaluable during the first twenty-four hours, when
the irritation caused by the action of the antiseptic on the tissues during an
operation renders the flow of bloody serum more free than it would be without
antiseptic management; but when the wound is of any considerable depth
they should be used so long as even trifling serous oozing continues. For if
the outlet proves insufficient for the free escape of the plasma still effused into
the interior, the fluid, accumulating in the cavity, gives rise to tension, and
hence to inflammatory disturbance, which may lead to suppuration and more
or less opening up of the wound.
As an illustration of the value of drainage-tubes in the later stages of the
treatment of wounds I may take a case of popliteal aneurysm in which I tied
the femoral artery last summer. The patient, a man thirty-eight years of age,
who had been a soldier, was admitted into the Royal Infirmary on the 16th of
June, with a swelling about as large as an orange in the left ham, with expansile
pulsation and thrill, and other signs of aneurysm ; and he stated that the swelling
had appeared suddenly five months previously, as he was sitting with his legs
crossed, accompanied by a throbbing sensation, which had since continued to
increase. The left leg was very weak, and was occasionally affected with darting
pains, and the foot was somewhat oedematous. He had a worn, cachectic
aspect, and the stethoscope indicated the presence of valvular disease of the
heart, both at the mitral and the aortic orifice. Believing that, brilliant as
are the results often obtained by compression, the patient’s interest will on the
average be best consulted by at once tying the femoral artery antiseptically,
provided that the catgut be thoroughly trustworthy, and that the operation
and after-treatment be really so conducted as to secure absence of putrefaction
in the wound, I applied a ligature on the 24th of June, turning aside the edge
of the sartorius so as to gain access to the vessel four inches and a half below
Poupart’s ligament, the situation which Mr. Syme used to advise in order to
ensure a Sufficient distance of the point of deligation from any considerable
arterial branch ; though indeed the antiseptic treatment seems to render this
consideration of comparatively little importance, a fact which this case itself
will be found to exemplify. The catgut employed was more substantial than
that commonly used for tying vessels in wounds, being rather more than one-
fiftieth of an inch thick. It had been prepared by myself more than a year
before by the method described elsewhere,’ and as the quality of the gut improves
the longer it is retained in the preparing liquid, I knew that this specimen was
* See Holmes’s System of Surgery, second edition, vol. v, p. 622.
DETAILS OF ANTISEPTIC SURGERY 219
thoroughly trustworthy. The ends of the gut were cut off near the reef-knot
in which it was tied. The operation was performed under the spray, and with
such precautions as the germ theory dictates.
And here I may take the opportunity of enforcing one of these precautions,
which I observe is apt to be overlooked. If a knife or other instrument, after
being used during an operation, is temporarily set aside or even withdrawn for
ever so short a time from the antiseptic atmosphere of the spray, it must be
cleansed afresh with carbolic lotion, whether by means of a sponge or by rubbing
it in the spray near the nozzle of the apparatus, where the liquid is little mixed
with air, otherwise septic material mingled with the blood on the instrument,
failing to be purified by merely passing rapidly through the spray, may be
carried in an active condition into the depths of the wound. This is one of those
essential points which I believe nothing but a knowledge of the great importance
of avoiding putrefaction and a lively sense of the presence of septic ferments
diffused in the world around us? will enable the operator to keep vigilantly
in mind.
The edges of the incision were brought together by carbolized silk sutures,
except at one part, where two drainage-tubes of rather small calibre were placed
side by side, communicating with the deepest part of the wound, and the gauze
dressing was applied as usual with a strip of oiled silk protective over the line
of incision, and the patient being put to bed, the foot and leg were enveloped
in cotton-wool. Next day, the dressing, being changed, was found extensively
stained with bloody serum, but there was no inflammatory blush or febrile
disturbance. On the following day the wound was again dressed, and one of
the drainage-tubes was removed. The spray was of course used in changing
the dressings, and I may remind the reader that it is of especial importance
that it be fairly directed on the wound during the withdrawal of a drainage-tube,
the place of which must necessarily be taken by air, which, if not purified by
the spray, will be likely to be septic.
The wound being exposed again after an interval of two days, the stitches
were found to be causing a little tension, and were therefore all removed ; but
* If any one chooses to assume that the septic material is not of the nature of living organisms,
but a so-called chemical ferment destitute of vitality, yet endowed with a power of self-multiplication
equal to that of the organism associated with it, such a notion, unwarranted though I believe it to be
by any scientific evidence, will in a practical point of view be equivalent to the germ theory, since
it will inculcate precisely the same methods of antiseptic management. It seems important that this
should be clearly understood, because it appears to be often imagined that authors who are not satisfied
of the strict truth of the germ theory, but substitute for it the other only possible hypothesis, invalidate
the antiseptic practice, which, I must repeat, is not affected in one tittle by this theoretical discrepancy.
* Prepared by immersing a reel of the silk in melted bees-wax mixed with about a tenth part of
carbolic acid, and drawing the thread through a dry cloth as it leaves the liquid, to remove superfluous
wax.
Q2
220 ON RECENT IMPROVEMENTS IN THE
the temperature was normal, and the serous oozing diminishing. Two days
later, or six days after the operation, the pain in the limb, of which he had
complained at the last dressing, had left him; but a considerable serous stain
being still found on the gauze, the drainage-tube was continued, though shortened
by cutting off a piece from the deeper end. Eight days after the operation the
cotton-wool was removed for the first time from the leg and ham. The foot
was free from oedema, and otherwise natural in appearance, and the aneurysmal
tumour had become greatly reduced, being now only a flattened mass about
one inch and a half across, free from pulsation. All trace of the jerking pain
he had in the limb before the operation had left him, and his general appearance
was much improved on what it was on admission. The wound being dressed,
the line of incision was found entirely healed, except at the point occupied by
the drainage-tube, and the serous stain on the dressing was so much diminished
that I reduced the little tube to a quarter of an inch in length, and allowed
three days to pass before the next dressing. On then exposing the wound,
however, I was disappointed to find the serous stain on the gauze fully as great
as on the last occasion, and pressure on the skin in the vicinity of the wound
caused a drop of clear serum to escape. This had never been seen before, and
implied that the shortened drainage-tube had not been answering its purpose
completely, but had permitted a certain amount of serum to accumulate; and
slight as this accumulation was, I knew from experience that it was enough
to perpetuate serous oozing by the tension which it occasioned. I therefore
substituted for the short drainage-tube another of the same calibre, but twice
as long—viz. half an inch, being as deep as it could be passed without violence,
and dressed again in two days. The result was such as I hoped. There was
an almost entire absence of serous stain on the gauze, and nothing could be
pressed out of the tube, which was now again slightly shortened. The dressing
was then left untouched for four days, when the drainage-tube was found lying
out of the wound, having been forced out by the consolidation going on in the
interior. There was almost no stain upon the gauze, and nothing could be
pressed out of the orifice where the tube had been. It was therefore finally
abandoned, and by the i1gth of July, twenty-one days after operation, the
dressing being changed after an interval of six days, cicatrization was found to
be complete, not a drop of pus having appeared from first to last.
So late as the 13th of July, seventeen days after the operation, or at a later
period than that at which a silk ligature applied without antiseptic means
commonly separates, pulsation could be felt in the femoral artery as low down
as the junction of the middle and lower thirds of the incision; or, in other
words, down to the very site of the ligature. It appeared, therefore, that some
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DETAILS OF ANTISEPTIC SURGERY 221
branch of unusually large size must have taken origin so close to the part tied
as to prevent entirely the formation of a superior coagulum ; and it is probable
that with an ordinary ligature the case might have terminated disastrously
from secondary haemorrhage. Thus we seem to have here an example of the
safety of the antiseptic ligature in the vicinity of a considerable arterial branch.
But to return to the point which this case is intended to illustrate—viz. the
value of the drainage-tube in the later stages of the treatment of wounds.
Supposing that instead of substituting a longer tube for the shorter one on
the eighth day after the operation, when a little serum was found to have
accumulated, I had then given up the use of the tube altogether, the probability
is that by the time of the next dressing, the outlet at the integument having
become partially occluded by granulation and contraction, a greater amount
of serum would have been pent up in the cavity, and that in course of time
the additional tension so occasioned would have led to suppuration and to the
opening up of the nearly cicatrized wound.
The effect of an accumulation of serum in keeping up inflammatory dis-
turbance, and the usefulness of the drainage-tube combined with antiseptic
management under such circumstances, are well exemplified by chronic bursitis
patellae, with fluid effused into the sac. The skin being washed with 1 to 20
carbolic lotion, a puncture is made under the spray with a tenotomy knife,
sufficient for the introduction of a drainage-tube scarcely larger than a crow-
quill, care being taken that it penetrates fairly into the cavity of the sac, which
often lies at a considerable depth in consequence of thickening of the membrane
and of surrounding textures. The narrow drainage-tube may be readily inserted
by means of a simple modification of the dressing forceps introduced by myself
several years ago, but hitherto unpublished. The blades, which are straight,
are ground down to the size of a probe at their extremities, as shown in the
accompanying sketch (p. 222), so that they can be passed into a very small
orifice. This instrument, which goes by the name of sinus-forceps among the
Edinburgh instrument-makers, will be found very useful for extracting small
exfoliations and for various other purposes.
The clear fluid contents being all pressed out of the sac, a gauze dressing
is applied, and retained in position with a figure-of-8 bandage. The dressing
being changed next day, the gauze is found considerably soaked with serous
discharge, but, if the tube is acting efficiently, nothing can be pressed out of
the cavity. And it will very likely be found that the end of the tube is pro-
jecting slightly above the level of the skin, and cannot be pushed in again to
its original position, so that it is necessary to shorten it a little. This depends
on the fact that, even within twenty-four hours of the opening of the sac, the
222 ON RECENT IMPROVEMENTS IN THE
chronic thickening of the textures has markedly subsided. The same thing
will be probably still more apparent when the dressing is again changed after
forty-eight hours more, when also the serous stain on the gauze resulting from
two days’ discharge will be only a small fraction of that seen after the first
twenty-four hours The tube being further shortened to the requisite degree,
the dressing now applied might be left untouched for a week so far as regards
the purpose of ensuring absence of putrefaction ; but
it will be well to expose the part again in two or three
days in order to ascertain whether or not the drainage-
tube may be dispensed with; the rule being that it
should be continued so long as the serous stain on the
gauze is more than the puncture, as distinguished
from the interior of the sac, would account for. This
is probably the case within a week of the opening of
the bursa; and then, the drainage-tube being dis-
continued, and a small piece of protective being
interposed between the puncture and the gauze so as
to permit cicatrization, the little sore will be found
completely healed in the course of another day or
two. At the same time the sac will be free from any
fluid accumulation, and the surrounding thickening
either quite gone or quickly disappearing.
While we have thus a sure, speedy, and (except
the infliction of the puncture) a painless? method of
remedying a troublesome complaint, the results are
of considerable theoretical interest. It is plain that
the antiseptic employed does not penetrate into the
bursa, so as to exert any direct action on the part
affected. All that the treatment does is, while
guarding against the access of putrefactive fermenta-
tion, to provide that the plasma poured out from the
synovial surface shall flow freely away as fast as it is effused and never accumu-
late in the cavity. Yet when these conditions are complied with, the obstinate
chronic inflammation, which has perhaps already resisted rest and counter-
irritation, immediately proceeds to subside, the morbid tendency of the synovial
membrane is soon entirely lost, and the surrounding inflammatory thickening is
* If it be desired, the puncture may be performed painlessly after congelation of the integument
by Richardson’s method with ether spray, the skin being washed with the carbolic lotion before freezing,
and the antiseptic spray substituted for the anaesthetic before the tenotome is introduced.
DETAILS OF ANTISEPTIC SURGERY 223
dispersed. It follows, therefore, that the presence of the fluid within the sac was
of itself sufficient to perpetuate for an indefinite period the state of chronic in-
flammation. And this fluid being the bland liquor sanguinis, perfectly destitute
of chemically irritating qualities, the only possible way in which it could have
produced its effect is by mechanical disturbance occasioned by its presence in
the sac. In other words, the agency by which the chronic bursitis was
maintained was that which, next to putrefaction, is the commonest of all causes
of inflammation in surgical practice—viz. tension. Yet, in cases of this kind,
the sac is by no means always extremely distended ; but, flaccid though it may
be, the fluid present in it keeps up by its mechanical influence the tendency to
abnormal effusion from the synovial surface and inflammatory hypertrophy
in the surrounding tissues. It seems to me important that this point should
be capable of being thus clearly demonstrated; because the knowledge that
a flaccid collection of liquid acts as a cause of disturbance not only serves to
explain the obstinacy of chronic serous and synovial effusions, but throws light
upon other important matters, such as the prejudicial effect of even a slight
accumulation of serum within a wound, as in the aneurysm case above related,
or the influence of the presence of the contents of a slack chronic abscess in
maintaining suppuration from the pyogenic membrane. And, conversely, this
knowledge enables as to understand the benefit often obtained by simply
evacuating serous or purulent collections, either as a single remedial measure
or as a preliminary to counter-irritation.
When the evacuation is effected in such cases by means of the aspirator,
the piercing cannula should be dipped into carbolic oil before introduction. And
if, as is often the case, the narrow tube becomes obstructed by lymph or curdy
material, there is no objection whatever to the use of an ordinary cannula and
trocar of any size that may be necessary, provided that the instruments be
smeared with the antiseptic oil and the operation be performed under the spray.
In abscesses, however, according to my experience, a cure rarely results from
evacuation of the contents by an opening which is allowed to close. The plasma
which exudes from the pyogenic membrane after withdrawal of the pus will,
if retained, nearly always occasion sufficient tension to reproduce suppuration.
But if it be allowed to flow freely away through a drainage-tube, under an
antiseptic dressing, the pyogenic membrane being freed from the disturbing
cause which urged it to perpetual suppuration before the abscess was opened
viz. inflammatory excitement occasioned by tension (greater or less according
to the degree of acuteness of the case), while the granulating sac is protected
from the new stimulus to which it would be subjected if the abscess were opened
without antiseptic measures—viz. the chemical irritation of putrefying material—
224 ON RECENT IMPROVEMENTS IN THE
the beautiful sight is witnessed of cessation of suppuration from the moment
that the original pus is evacuated, the serous discharge diminishing constantly
till the abscess cavity is closed.
If antiseptic treatment had done nothing more than create such a revolution
in the treatment of abscess and throw such light upon its pathology, it would
have well deserved the gratitude of the surgeon.
But in order that such results may be obtained, it is necessary that both
the above conditions be complied with—viz. a perfectly free outlet for discharge,
and thoroughly efficient antiseptic management from first to last. If the former
condition be not fulfilled, inflammatory suppuration from tension will occur ;
or if the accumulation of fluid be only to a very slight extent, increase or per-
sistence of serous oozing will be the result. And if the latter essential fail to
be maintained—as, for example, through inefficiency of the retaining bandage,
allowing the dressing to become loose or displaced, or through the antiseptic
treatment being given up too early, before the sinus has completely closed—
septic suppuration will take place, with its various consequences, such as free
incisions and counter-openings, or, in vertebral or articular disease, disaster
varying according to the circumstances of the case.
A sponge wrung out of a strong watery solution of carbolic acid (1 to 20)
forms a valuable aid to the drainage-tube in preventing, during the first twenty-
four hours, the accumulation of blood in wounds having a considerable cavity,
such as those left after the removal of tumours.'. The wound having been
stitched and the drainage-tube (or tubes) inserted, a strip of oiled silk protective
is laid along the line of incision to keep it moist, and so prevent the sponge
from adhering. A soft sponge, large enough to cover the entire cavity of the
wound and purified as aforesaid, is then applied, and over it a gauze dressing
sufficiently extensive to reach several inches beyond the sponge in every direction.
The whole is retained in position by a pretty firm bandage, so as to bring into
play the elasticity of the sponge, which keeps the surfaces of the wound in
apposition, and, while checking sanguineous effusion, compels that which does
occur to escape by the drainage-tube, when it is at once sucked up by the sponge
as it oozes from beneath the protective.
If any one desires proof of the potency of astrong watery solution of carbolic
acid to deprive septic ferments of their energy, he cannot do better than consider
the results of this mode of dressing. The same sponges are used over and over
again till they wear out, and for hospital purposes they are kept always steeping
* The sponge had long been a favourite application of Mr. Syme’s under such circumstances, and
he was the first to use it antiseptically. The case was one of very large parotid tumour, in a woman
advanced in years ; and the dressing employed was a large sponge squeezed out of carbolic oil, which
answered its purpose admirably.
DETAILS OF ANTISEPTIC SURGERY 225
in the carbolic lotion. But in private practice the plan which I have pursued
for several years is the following : The sponges, after being used for an operation,
are put into a vessel of water and left there till the fibrine in their pores has
been converted by putrefaction into a slimy liquid which can be readily washed
out. They are then squeezed in successive portions of water till they cease to
discolour it, and, after having been well wrung, they are thoroughly moistened
with the 1 to 20 watery solution of carbolic acid. The sponges after being so
treated have, very likely, a decided putrefactive odour clinging to them: but
this is a matter of no moment. The presence of a little of the products of putre-
faction will do no harm if the causes of the fermentation have been destroyed.
And that such is the case is evident from the following considerations : The
sponge, being squeezed as dry as possible when applied, contains but little of
the solution of carbolic acid with which it was treated, and this is soon displaced
from the parts next the wound, or at least copiously diluted by the efiused
blood and serum, which are often in such quantity that the red liquid can be
wrung out of the sponge when it is removed on the following day. If, therefore,
any septic ferment were present in an active state in the deeper parts of the
sponge, the bloody serum could not fail to putrefy, since there is certainly not
a sufficient proportion of carbolic acid mixed with it to act as an antiseptic.
Yet, in point of fact, putrefaction never does occur in the sponge (provided,
of course, that all the proceedings have been, in other respects, conducted anti-
septically), and I cannot call to mind a single instance of such an occurrence
either in private or hospital practice. It follows that no active septic ferment
is present in the portions of such a sponge which become soaked with the serum.
Yet before the sponge was treated with the solution of carbolic acid it contained
such ferments in abundance ; for, not to speak of the residual putrid material
left after the often hasty and imperfect washing, the very water with which
it was washed teemed with septic ferments, as was clearly demonstrated some
years ago by Dr. Burdon Sanderson.! How, then, had they been got rid of ?
They could not be all washed out like the carbolic acid, because, as will be shown
in the next paragraph, they are not matter in solution, but solid particles, which
must remain entangled in abundance in the porous material of the sponge.
The only other possible way in which they can have been disposed of is by the
action of the carbolic acid upon them. And thus we are led inevitably to the
conclusion that this agent, applied in the form of a strong watery solution,
completely and permanently extinguishes the septic energy of putrefactive
ferments.
That the septic ferments are solid particles, not material in solution, might
* See Dr. Sanderson’s paper in the Quarterly Journal of Microscopical Sctence, 1871.
226 ON RECENT IMPROVEMENTS IN THE
be pretty safely assumed from analogy, if it were granted that they are living
organisms ; though, indeed, I once heard it propounded in conversation by
a very sound and eminent chemist that, for aught we could tell to the contrary
living matter in its lowest forms might exist in a soluble condition—an idea
suggested by Dr. Sanderson’s statement that a drop of water in which no
bacteria could be discovered by the microscope will nevertheless give rise to
the development of such organisms when added to a liquid adapted for their
growth. But those who hold that the septic agents are not organisms at all,
but so-called chemical ferments, might with greater justice contend for their
possible solubility. The point being of great practical as well as speculative
interest, I have been glad to obtain conclusive evidence regarding it from some
simple experiments lately performed, and hitherto unpublished. I must content
myself on the present occasion with briefly indicating their character.
A series of experimental glasses, contrived so that their contents shall be
securely protected from dust, though the atmospheric gases gain free access
to them, having been purified by heat, are charged with some liquid, like boiled
milk, favourable for organic development and prone to fermentative changes,
but uncontaminated at the outset by the presence of any living organism.’ If
the glasses so arranged are left undisturbed, the liquid remains unaltered for
an indefinite period, except that its bulk is slowly diminished by evaporation.
But if a minim of ordinary drinking-water is added to any one of the glasses,
its contents will in a few days be obviously altered in chemical character, and
before long will probably be decidedly putrid, the microscope at the same time
revealing abounding bacteria—a result in perfect accordance with Dr. Sander-
son’s observations. If, however, instead of an entire minim, a small portion
(say a hundredth) of a minim of the same water is added to each of a series
(say ten) of such glasses (which can be readily done by means of a small syringe,”
having its piston-rod in the form of a fine-threaded screw, on which a graduated
disc revolves to regulate the amount of liquid emitted from the slender glass
tube that constitutes the nozzle of the instrument), a very different result ensues.
Some of the glasses probably remain permanently unchanged, as if nothing
had been added to them ; and those which do experience alteration show plainly,
by differences of colour and of smell, that they are undergoing various kinds
of fermentation, while the microscope shows corresponding differences in the
characters of the bacteria found in them.
It is hardly needful to remark that if the ferments were dissolved in the
* For an account of the manner in which these conditions are fulfilled see a paper by the author
entitled ‘A further Contribution to the Natural History of Bacteria’, &c. (Microscopical Journal,
October 1873). (See vol. i, p. 300.) 2 See vol. i, pp. 364-5.
DETAILS OF ANTISEPTIC SURGERY 227
water they would be equably diffused through it, and the same effects would
be produced in all the glasses by the addition to each of the same quantity,
however small. It is thus conclusively shown, so far at least as regards the
fluids which I have hitherto made the subjects of experiment, that the material
in water which leads to putrefaction or other fermentative changes in an organic
liquid is not in a state of solution, but in the form of suspended particles, various
in kind and, though present in great numbers, by no means equably diffused,
but scattered through the water at various distances, like the amoebae or other
animalcules which people it. This will, I believe, be found to be a sure and
important step in proof of the theory upon which the antiseptic treatment is
based. But a practical paper like the present is perhaps hardly the proper
place for discussing its bearings in this respect.
I have now to speak of improvements in our practice connected with the
introduction of new antiseptic substances.
About three years ago my friend, Dr. Stang, of Sorweg, in Norway, being
on a visit to Edinburgh, informed me that a new antiseptic had been discovered
in Sweden, and was already extensively used in that country for the preservation
of articles of food, and also as an application to wounds. The ‘aseptin’, as it
was termed, was in two forms, a powder and a liquid, the latter receiving the
additional title of ‘amykos’. The composition of the preparations was kept
secret ; but there was little doubt that they owed their virtue to one common
ingredient ; and he promised to send me samples of them, in the hope that
they might prove useful in carrying out the antiseptic principle in surgery.
This promise he at once fulfilled on returning home, at the same time telling me
that the active principle of both the articles had been ascertained to be boracic
acid, the virtues of which had been discovered by Mr. Gahn, a chemist in Upsala.
It happened that I was just then suffering from onychia of the little finger,
attended with excessive fetor, and at the same time exquisitely sensitive, so
that even a very weak watery solution of carbolic acid caused almost intolerable
pain, while it entirely failed to subdue the pungent ammoniacal odour. I at
once gave a trial to the amykos, using it just in the same manner as the former
lotion, dropping some of the liquid upon the tip of the finger and wrapping
it in lint soaked with the same fluid and covered with gutta-percha tissue. The
drops of the amykos, as they fell upon the sensitive surface, caused not the
slightest twinge of uneasiness ; yet when I changed the dressing, after the usual
interval, I was surprised to find an almost entire absence of fetor. Here, then,
I had at once sufficient evidence that the new antiseptic, when employed in the
form of watery solution, was both highly efficient and much less irritating than
carbolic acid.
228 ON RECENT IMPROVEMENTS IN THE
Boracic acid was then little more than a chemical curiosity. But I suc-
ceeded in obtaining in Edinburgh a sufficient quantity to enable me to test
its properties unmixed with other ingredients. A striking instance of its anti-
septic efficacy as well as of its therapeutic value was at once presented by a case
of pruritus ani of upwards of ten years’ standing. The affected part was washed
with a saturated watery solution at bedtime, and a small piece of lint soaked
with the same lotion was applied and retained during the night. The result was
immediate relief from the accustomed irritation, and, what struck me as
extremely remarkable, the bit of lint, when removed next morning, was free
from smell. It was afterwards found that even the slight mechanical irritation
caused by the presence of the lint might be avoided; for the mere application
of a few drops of the watery solution last thing at night, the part being left
moist with the liquid, proved completely efficacious ; and this simple treatment
being continued for a while, the obstinate tendency to irritation gradually dis-
appeared, while the thickening of the folds of skin, which had been of several
years’ duration, entirely subsided.
Another example of the usefulness of the new remedy was furnished about
the same time by a case of inveterate eczema of the ankles in a lady above the
middle period of life. The water dressing which she used being removed, a very
unusually fetid odour was exhaled from the moist scarlet surface, which, tender
as it was, she was impelled to scratch by an intolerable sense of itching. Thinking
that here, as in the case of pruritus, the irritation caused by putrefaction might
be a main element in the obstinacy and discomfort of the complaint, I gave
the boracic acid a trial, substituting a saturated watery solution for the water
in the dressing previously employed. The effect was at once to correct the
fetor, but in this case the application occasioned a good deal of persistent
uneasiness in the sensitive surface. The patient, however, persevered with the
treatment, and in a short time the ankles were both in a sound condition, which
I was lately glad to learn had proved permanent.
But, striking as were these evidences of the antiseptic virtue of boracic
acid, I knew well that in the form in which I had hitherto tried it—namely,
in lint soaked with a watery solution—it could not answer for a permanent
antiseptic dressing under circumstances where there is at all a free discharge.
For the putrescible fluid soaking into the lint would drive the antiseptic before
it, and occupy its place, and as soon as this had occurred throughout the thick-
ness of the dressing at any one point, putrefactive fermentation would be free
to spread into the wound. In order that the dressing might be trustworthy
it was necessary that the boracic acid should be in some way stored up in it, as
carbolic acid is in the resin of the gauze, so that it could not be at once washed
DETAILS OF ANTISEPTIC SURGERY 229
out from it by the discharge. A ready means of attaining this object was
presented by the fact that the acid, though but sparingly soluble in water at
ordinary temperatures, is pretty freely dissolved at the boiling-point. Thus,
at 60° Fahr. water takes up only about a twenty-sixth part of its weight, and
at 100° less than a sixteenth, but at 212° more than a third. Hence if a piece
of lint is dipped in a saturated solution near the boiling-point, it absorbs a great
deal of the acid, and, after being allowed to dry, it is found to weigh about
twice as much as it did originally, the weight of the crystals disseminated through
it being nearly equal to that of the lint itself. If, therefore, this ‘ boracic lint’
is used as a dressing the discharge may soak through it repeatedly without
dissolving out all the acid, although it takes up in its passage a sufficient amount
to render it antiseptic. It is further a fortunate circumstance that the crystals
of boracic acid, instead of being hard and harsh, like most crystals, are soft and
unctuous, and therefore occasion no mechanical irritation of the skin.
The boracic lint has proved very valuable in the treatment of ulcers of
the legs or elsewhere. In dealing with them, the first step is to cleanse the
sore and the surrounding skin once for all from septic impurity. This is done
by treating the surface of the sore freely with a solution of chloride of zinc (forty
grains to the ounce), and at the same time washing the integument with a strong
watery solution of carbolic acid, which is used on account of its remarkable
power of penetrating the epidermis, while for the sore itself the solution of the
chloride appears to be more efficient. This preliminary step having been taken,
the boracic dressing is at once employed as follows: A piece of oiled silk pro-
tective, of sufficient size to cover the sore and slightly overlap the surrounding
skin, is dipped in the boracic lotion (a saturated watery solution) and applied,
and over this a piece of boracic lint large enough to extend for an inch or more
beyond the protective on all sides, the whole being retained in position with
a bandage. It is well to soak the boracic lint with the lotion before putting
it on, not for the sake of adding more of the acid, but because the lint, when
applied moist and allowed to dry on, is less liable to slip afterwards from its
position, and also for the purpose of purifying the surface of the lint itself,
which in the dry state has no power of acting upon septic dust adhering to it,
the acid which it contains being non-volatile, and, therefore, only acting when
in solution.
In this dressing the protective serves its usual purpose of preventing as
much as possible the direct action of the antiseptic upon the healing part ;
and although boracic acid interferes with cicatrization much less than carbolic
acid does, the epidermic development proceeds more quickly when it is excluded,
while the formation of pus due to the stimulation of the surface of the granula-
230 ON RECENT IMPROVEMENTS IN THE
tions by the acid (antiseptic suppuration) * is of course diminished ; and the less
the discharge, the less frequently is it needful to change the dressing. The
protective also keeps the surface of the sore moist, and so prevents the discharge
from being pent up and causing inflammatory disturbance from tension, as is
apt to be the case beneath the crust of inspissated pus in a dry dressing. The
lint is also kept from sticking to the sore and tearing off the newly formed
epidermis when it is removed.
But it must always be remembered that the protective, in proportion to
the efficiency with which it discharges its function of preventing the irritation
of the acid, excludes also its antiseptic virtue, so that if putrefactive material
exists beneath it at any one point, the septic fermentation will spread over the
whole sore. Hence the necessity for having the boracic lint to extend on all
sides beyond the oiled silk, for if the protective were to escape at any one place
from under cover of the antiseptic layer, it would necessarily conduct putre-
faction inwards beneath it. Hence also the importance of adopting thoroughly
efficient means of purifying the sore as a preliminary measure.
But if those points are attended to, this mode of dressing will be found
to yield excellent results. The epithelial development, protected from needless
disturbance, proceeds at a rate altogether unknown under water dressing, and
cicatrization will often advance steadily in sores which, under ordinary treatment,
cannot be got to heal at all; as when, through the unyielding character of
surrounding parts, the shrinking of a large granulating surface has put the
imperfect textures of the sore upon the stretch, and thus so reduced their vital
power as to make them liable to ulceration or sloughing under the influence of
stimuli which fail to arrest the healing of an ordinary vigorous sore, such as
solutions of astringent salts or the degree of putrefaction that occurs in water
dressing within twenty-four hours. This application also saves trouble to the
surgeon, for if properly used, it may be left unchanged for a period varying
from two to five days, according to the amount of the discharge.
This last circumstance, together with the unirritating character of the
dressing, makes it peculiarly useful for skin-grafting. The manner in which
I have for a considerable time carried out Reverdin’s beautiful principle is as
follows : The skin of the inner side of the upper arm having been lightly washed
with I to 20 watery solution of carbolic acid to purify its surface, a thin layer
of the integument is shaved off with a very sharp knife, so as to take barely
more than the epidermis, scarcely drawing blood or causing pain. The little
shaving is placed upon the thumb-nail of the left hand, moistened with a drop
of the boracic solution, and bits not bigger than pins’ heads are successively
niSee-aDOve, Pp. 1409.
DETAILS OF ANTISEPTIC SURGERY 231
+
cut off and laid upon the surface with which they are to unite, by taking up
each graft upon one side of the point of the knife and stroking the other side
of the instrument upon the granulations so as to have the graft behind. Care
must be taken that the deeper surface of the graft is placed downwards, but
this is readily done from the fact that the shaving always curls up with the
deeper aspect on its concavity.
It is an interesting pathological fact brought out by this mode of procedure,
that the surface of healthy granulations is as prone to adhere to freshly cut
perfect tissues as granulations are to coalesce with each other, or the sides of
a recent wound to unite by first intention. The practice often followed of
cutting beds in the granulations to receive the grafts, very inconvenient from
the bleeding which it involves, is therefore wholly unnecessary. The several
pieces of epidermis, of which twelve are furnished by a slice a sixth of an inch
square, if simply applied to the uninjured surface of the sore, will probably
be found to afford as many starting-points for cicatrization, provided that the
granulations are healthy to begin with, and that all needless irritation of the
grafts is avoided. As regards the former condition, it is a great mistake to
wait till healing has considerably advanced, and the sore has become already
stretched and weakened by its own contractions ; and, as regards the latter
point, the avoidance of needless irritation, the stimulus of putrefying materials
must be got rid of by thoroughly purifying the sore as a preliminary measure,
while the irritation of the antiseptic itself is reduced to a minimum by the
dressing employed. In order to make sure against septic contamination during
the process of grafting, it is well to cover the sore as soon as it is exposed with
a piece of muslin dipped in the boracic solution, and uncover successive portions
for the application of the grafts. Then, as each graft is put down, it is covered
at once with a small piece of protective dipped in the lotion, and at the conclu-
sion of the process any parts of the granulating surface remaining exposed are
covered in either by separate pieces of protective or by a general piece over the
whole, as no harm is done by the layer being double. Boracic lint wrung out
of the lotion, and well overlapping the surrounding skin, is then applied, two
layers being used at the more dependent parts if the sore is large and much
discharge expected, and a retaining bandage is put lightly on. This dressing
is left untouched for two or three days ; and when it is changed, all the protective
will be found to come off as one piece adhering to the lint, but not sticking
at all to grafts or granulations, which are covered with a layer of pus or lymph.
This being free from putrefaction or any other irritating property, there is no
need to wash the surface of the sore, a process which might disturb the grafts ;
but without any delay a fresh piece of dipped protective is applied, and over
232 ON RECENT IMPROVEMENTS IN THE
it the moistened boracic lint, any crusts of inspissated discharge on the sur-
rounding skin being afterwards washed away at leisure with the lotion. When
the dressing is next changed, the red ring of youngest cicatrix will probably be
already apparent around each white epidermic islet.
The trifling wound on the arm which furnished the grafts is treated, like the
sore, with protective and boracic lint, and, if these be properly secured, a scar
will be found in its place when the part is exposed after the lapse of a few days.
To be able thus to treat recent abrasions with a single application, which
may be left undisturbed for an indefinite period, is often a matter of great con-
venience, especially in the case which so frequently presents itself where such
superficial injuries are present as complications of simple fracture. Here,
without antiseptic management, troublesome sores are liable to form, requiring
frequent disturbance of the splints to gain access to them for daily dressing.
But after washing the part with (1 to 20) carbolic lotion, and applying the
dressing of protective and boracic lint, the abrasions may be dismissed from
further consideration.
It is, of course, essential for the success of this dressing that it should be
kept accurately in position. In the case of abrasion in fracture this is probably
ensured by the presence of the splints, and in large sores upon the legs it is
readily done by means of a bandage, especially one made of the antiseptic gauze,
which, as before observed, is less apt to shift its place than a common cotton
roller. But for small dressings in any situation, and especially about the face,
where bandages cannot well be used, it will be found very convenient to fix the
boracic lint by means of collodion applied to the edges of a piece of cotton cloth
of open texture, sufficiently large to overlap the skin on all sides around the
lint. The cloth used for making the antiseptic gauze answers the purpose very
well, only it must be employed unprepared, because the resin and paraffin of
the prepared gauze would prevent the ether of the collodion from evaporating.
In absence of the unprepared gauze, a piece of ordinary rag may be used, if
the edges are frayed out sufficiently to give the collodion a proper hold upon
the skin.
The boracic lint may often be employed with great advantage as a moist
application, soaked with the boracic lotion, and covered with gutta-percha
tissue or oiled silk. Foul ulcers, coated with a layer of putrid slough or lymph,
if dressed daily in this way, will probably soon assume healthy characters ;
and when this has occurred, a comparatively slight washing of the sore with
the chloride-of-zine solution will be sufficient for the final purification, pre-
liminary to using the dressing with protective and dry boracic lint; whereas
if the chloride is used at the outset, while the sore is covered with its foul crust,
DETAILS OF ANTISEPTIC SURGERY 233
—
a very energetic application is required, entailing hours of considerable uneasi-
ness to the patient.
In deep burns, where from any cause the sloughs have been allowed to
putrefy, the moist boracic lint will be found an excellent dressing. In a case
lately under my care, the gluteal region having been extensively and deeply
burnt, the vicinity of the perineum made it impossible to keep out putrefactive
fermentation. Here accordingly a daily dressing of lint, steeped in one part
of carbolic acid to thirty of olive oil, and covered with gutta-percha tissue,
was employed ; but, in spite of this application, the air of the room was pervaded
with a strong putrid smell. I therefore substituted for the carbolic oil a dressing
of moist boracic lint, and, at my next visit, was glad to find the apartment free
from unpleasant odour, although, the sloughs having not yet separated, the
emanations would doubtless have been even more offensive than before had the
previous dressing been continued. I was, therefore, now able to direct that
the boracic lint should be changed only every other day, instead of having the
patient disturbed and pained by a daily dressing. And, further, when the
sloughs had separated, feeling sure that, by virtue of the boracic acid stored
up in the lint, putrefaction would be less advanced in three days under it than
it would have been in twenty-four hours under water dressing, I felt justified
in allowing this still longer period of tranquillity.
This is a sufficiently striking illustration of the value of the boracic lint as
a moist application in all circumstances in which putrid sloughs are present
in parts superficially situated, so that the antiseptic can gain access to them.
And while the boracic acid gradually dissolved out of the lint by the discharges
has this powerful effect in diminishing or arresting putrefaction, it also generally
allows cicatrization to proceed kindly in such parts as are already cleansed of
sloughs, though the healing is not so rapid as where the direct action of the
acid is excluded by protective over a purified sore.
If much inflammation is present around putrid sloughs, wet boracic lint
applied to the sloughs, and a poultice outside this and extending over the whole
inflamed integument, will be found to work extremely well. The boracic lint may
be left undisturbed for twenty-four hours or more, while the poultice is changed
as often as may be desired.
The moist boracic lint is also a convenient dressing after operations upon
the penis. Here the frequent exposure of the part for the purpose of micturition
makes it necessary to entrust the antiseptic management on each occasion to
the patient himself, so that some very simple arrangement is indispensable.
With this object a strip of the moist boracic lint may be wound round the organ
and secured in position by a piece of thread or narrow bandage, so as to cover
LISTER II R
234 ON RECENT IMPROVEMENTS IN THE
the wound but leave the meatus urinarius free; and outside this permanent
part of the dressing a loose piece of the wet boracic lint is wrapped and covered
with gutta-percha tissue. Then at each time of micturition the patient removes
the outer piece of lint, and readjusts it at the conclusion of the act, after pouring
over the part a little of the boracic lotion. The unirritating character of the
solution of boracic acid to mucous membranes, which is a peculiar feature of
this antiseptic, prevents any inconvenience to the urethra from such treatment,
which at the same time affords perfect security against putrefaction, yet allows
healing to proceed kindly.
The most frequent case of operations in this situation is that for phimosis.
It is now about ten years since it was pointed out by Mr. Furneaux Jordan,
of Birmingham, that sutures are unnecessary after this operation, and that,
after notching the narrow ring of the preputial orifice at one or more situations
according to its tightness, and slitting up the inner layer of integument which
embraces the glans, to a sufficient degree to permit free retraction, all that is
required is to employ a simple dressing and to make a point of having the glans
freely exposed once in twenty-four hours; the result being avoidance of the
unseemly notch which the stitch, if it really answered its purpose, inevitably
occasioned. Ever since the publication of this simple method I have invariably
followed it, and, as a rule, with great advantage; but not infrequently the
attainment of the object has been seriously interfered with by inflammatory
swelling. But if putrefaction, which is the main cause of disturbance after
this operation, is prevented by the boracic dressing, the oedematous puffiness
of the prepuce, otherwise so apt to give trouble, is almost entirely avoided,
provided that the incisions have been made sufficiently free to allow the utmost
facility of retraction. It is, however, essential to the success of the antiseptic
dressing that the organ should be thoroughly purified at the outset, as by washing
the interior of the prepuce and the glans at the conclusion of the operation
with saturated watery solution of carbolic acid (1 to 20), completely removing
any portions of epithelial accumulation adhering about the frenum and corona.
A narrow strip of the boracic lint is then wound round the neck of the organ
and the retracted prepuce, with the object of keeping the parts in this position,
except once a day when the skin is drawn freely forwards and again retracted.
But if, as is often the case, there is an insuperable tendency of the skin to slip
forwards, the permanent dressing may be dispensed with, the general covering
of boracic lint being alone employed, with very free use of the lotion after each
act of micturition, together with complete retraction once in twenty-four hours.
The last case in which I was called upon to operate for cancer of the penis
may be given as another illustration of the value of this dressing. The integu-
DETAITS OF ANTISEPTIC SURGERY 235
ment being, as usual, less implicated than the spongy and cavernous structures,
I proceeded as in a modified circular amputation in a limb, dividing the skin
sufficiently in advance of the deeper parts to form a covering for them, and
cutting its margin in the shape of short antero-posterior semilunar flaps which
might be accurately adjusted without puckering, the removal being completed
by a transverse stroke of the knife after retraction of the loose investment.
I next sought to carry out the valuable principle first suggested by the late
Mr. Teale, of Leeds,’ of endeavouring to obtain union by first intention of the
mucous membrane and the skin, so as to prevent subsequent contraction of the
orifice. I first slit up the urethra longitudinally at its inferior part for about
a third of an inch from its transversely divided extremity in the stump, as
advised by Teale, and then perforated the tegumentary pouch at its ventral
aspect by a cut equal in length to that in the urethra, taking care that the two
openings should exactly correspond in position, and stitched the edges of the
hole in the skin accurately, with silver wire at the angles and horsehair along
the sides, to the margins of the mucous membrane, paring off the angles of the
latter so as to form an oblique oval orifice to the urethra. The edges of the
little skin-flaps were now also brought closely together with horsehair stitches,
except in the centre, where a drainage-tube of crowquill size was inserted to
prevent tension from accumulating blood and serum. The operation was
performed under the spray, after the skin had been cleansed with a I to 20
carbolic lotion. The vessels having been tied with fine catgut, moist boracic
lint was carefully adjusted so as to cover the end of the stump, but leave the
urethral orifice exposed ; and outside this permanent dressing a loose piece of
the wet boracic lint was wrapped and covered with gutta-percha tissue, tied
with the split end of a bandage which encircled the pelvis. This outer dressing
was of course removed by the patient for micturition, and readjusted after
washing with boracic solution; but the deep dressing was left untouched for
two days, when it was taken off, entirely free from urinous odour, and, the
drainage-tube having been taken out, fresh boracic lint was applied in the same
way. The wound was again inspected two days later, and, as there was not
the slightest inflammatory blush, and the stitches were evidently occasioning
no tension, they were left undisturbed for three days longer, when they were
found still lying in their places as they were after the operation a week before,
and on their removal the cutaneous and mucous surfaces were found connected
all round the urethral orifice in a line of perfect primary union, and the wound
* Quoted in Holmes’s Surgery, second edition, vol. v, p. 181, by Professor Humphry, who, however
proposes another mode of procedure, which suggested to me the idea of providing a covering of skin
for the end of the stump in combination with Teale’s plan.
R 2
236 ON RECENT IMPROVEMENTS IN THE
over the end of the stump was likewise entirely healed except the part where
the drainage-tube had lain. The same dressing was continued till this spot
also had cicatrized, the blood-clot within the pouch of skin becoming organized
without suppuration ; and the patient left the hospital three weeks after the
operation, having suffered literally no pain or inconvenience from first to last,
and with a remarkably natural appearance of the part.
This case illustrates well, though on a small scale, the whole subject of this
paper. Without antiseptic measures the careful fitting and close stitching of
the parts would in all likelihood have been so much trouble thrown away. The
wound at the end of the stump would probably in a few days have been freely
opened up through suppuration due to putrefaction of the blood-clot in the
investing pouch, and the stitches around the urethral orifice would soon have
cut their way out under the influence of acrid ammoniacal urine. Again, even
though putrefaction had been prevented, had the little drainage-tube been
omitted and an additional stitch inserted in its place, tension from accumulated
blood and serum would have arisen, producing inflammatory disturbance which
might have marred the whole result. And, lastly, if an antiseptic more irritating
to the skin or mucous membrane had been kept in contact with the wounds,
it would, in proportion to the degree of its irritating property, have interfered
with the primary union both at the new meatus urinarius and at the end of
the organ.
It is with regard to this last point that the special value of boracic acid
is exemplified. In such a situation it would have been practically impossible
to maintain in position a protective layer such as is used under a dressing of
carbolic acid; but, thanks to the mildness of the watery solution of boracic
acid, the absence of such protective and the frequent copious ablutions with the
antiseptic were productive of no disadvantage.
In further illustration of the value of the wet boracic lint for operations
in this situation I may mention a case of aggravated hypospadias under my
care last winter. The floor of the urethra was deficient from the end of the
penis to about the middle of the scrotum, which in its cleft condition resembled
at first sight the labia of a female; and for about three-quarters of an inch
from the end of the glans the mucous membrane was entirely absent, a shallow
sulcus lined with the integument being the only indication of the canal. The
mode of procedure adopted was as follows: A straight rod, as large as a full-sized
catheter, being held vertical by an assistant, with its extremity inserted in the
orifice of the complete part of the urethra in the scrotum, the skin of the penis
and front of the scrotum, by virtue of its extreme laxity, could be readily made
to slip upon itself so as to cover in the straight bougie, meeting in two folds
DETAILS OF ANTISEPTIC SURGERY 237
in the middle line, and my object was to get the margins of these folds to unite
by paring them and stitching them together, so as to complete the urethra
with epidermis-covered skin on the internal as well as the external surface.
But, as I knew that perfect absence of tension in the uniting parts would be
essential to success, I freed the skin by three preliminary incisions, one in the
middle line of the dorsum of the penis throughout its length except the preputial
margin, and two in the anterior part of the scrotum, obliquely placed so as to
be more or less parallel to the urethra at that situation. These incisions gaping
widely permitted the cutaneous folds to meet with the utmost freedom in the
situation of the proposed raphe, and their rounded margins being pared off,
they were closely sewn together with deep sutures of silver wire and intermediate
superficial ones of horsehair for accurate approximation of the external cutaneous
edges, the wounds at the sites of the preliminary incisions being left to heal
as they might.
As regards the antiseptic measures, the penis and scrotum were thoroughly
washed with 1 to 20 carbolic lotion before the operation, which was performed
throughout under the spray, as it was of essential importance to avoid the
presence of any septic material in the blood-clots which might collect between
the approximated raw surfaces or in the interior of the new urethra. Then
with respect to the subsequent avoidance of the access of putrefaction, I knew
that no contamination would come from within—that is to say, from the sound
part of the urethra—because it had been abundantly established by experiments
which I had made with reference to the germ theory of fermentative changes’?
that a perfectly healthy urethral mucous membrane is free to its extreme orifice
from septic organisms. All that was needed, therefore, was an efficient external
antiseptic dressing, mild enough in its action to permit healing to take place
beneath it, for which purpose wet boracic lint was the most eligible. But
there was this peculiarity in the present case, as compared with that of cancer
of the penis above recorded, that the patient, being only six years old, could
not be entrusted with the management of any part of the dressing on the occa-
sions of micturition ; and even if a special nurse were provided for this charge,
there would be great risk of negligence on her part letting in the septic mischief.
This difficulty was got over by never allowing the parts to be exposed at all,
either by nurse or patient, but keeping them permanently covered with a mass
of moist boracic lint, securely fixed in position by stitching it to a T bandage,
the ends of the split longitudinal part of which were not only attached to the
part that encircled the pelvis, but were also carried round the upper parts of
the thighs and crossed over the perineum. Over this permanent dressing was
1 See ‘A further Contribution to the Natural History of Bacteria’, &c. (See vol. 1, p. 309.)
238 ON. RECENT IMPROVEMENTS IN THE
applied an apron of wet boracic lint and gutta-percha tissue, fixed by an ordinary
T bandage, which could be loosened at pleasure; and directions were given
to the nurse that when the boy, whose hands were tied out of harm’s way, wished
to relieve the bladder she should loosen the outer bandage, and, raising the
apron, allow him to pass his water through the mass of the permanent dressing
into a bed-pan placed beneath him to receive the urine and also a copious
effusion of saturated boracic solution which was to be poured on at the con-
clusion of the act; after which the apron was to be readjusted. This plan
answered completely : there was nothing to indicate inflammatory disturbance ;
and when, after the lapse of about a fortnight, the stitches were removed,
perfect union was found to have taken place along the middle line, except a small
oval aperture about the base of the prepuce and a minute orifice, like a pin’s
point, at the scrotum, which now no longer suggested by its form the characters
of the other sex. The retractile preputial covering of the glans was quite natural
in appearance, except the oval aperture before mentioned, which will no doubt
be readily closed at a future period ; and the new canal, being formed of non-
contractile material, is sure to remain of adequate calibre. The sores resulting
from the incisions were at the same period far advanced in healing, and their
cicatrization was soon completed under a continuance of the same mode of
dressing.
There can be no doubt that the irritation caused by fermenting urine has
hitherto been a great cause of failure in plastic operations in this situation ;
for which, therefore, we may fairly anticipate a far greater measure of success
mete: future:
While this paper has been going through the press, another case has occurred
so illustrative of this department of the subject that it seems deserving of intro-
duction. A boy nine years old being brought to me on account of difficulty of
micturition, I found that though, on superficial inspection, the meatus urinarius
appeared natural, it was merely represented by a shallow sulcus in the integu-
ment, except at the posterior extremity, where an orifice existed so minute as
only to admit the eyed end of a fine sewing needle. It would have been an
easy matter to have extended this aperture by cutting backwards; for the
soft parts between the urethra and the surface were very thin at the ventral
aspect of the organ, so that the edges of the divided skin and mucous membrane
could have been readily brought together by sutures for primary union. But such
a procedure would have resulted in an inferiorly situated meatus urinarlus, or,
in other words, a degree of hypospadias. On the other hand, to cut forwards
through the substantial spongy texture of the glans seemed at first sight most
unpromising, because it would be impossible to cover in the wound with skin
DETAILS OF ANTISEPTIC SURGERY 239
or mucous membrane, and the lateral granulating surfaces which must result
would have a powerful tendency to coalescence at their angle of union in front.
But on reflection I determined to try this latter method, in the hope that a more
favourable issue might be obtained through avoiding as much as possible all
irritation of the divided textures, by providing a smooth metallic surface for
contact with them, and at the same time preventing the urine from becoming
acrid through putrefaction. The operation was performed, on the gth of March,
by making successive notches forwards with a tenotomy knife guided by succes-
sively larger metallic rods till the incision extended through the whole length
of the superficial sulcus which indicated the natural position of the meatus,
and a No. 12 bougie could be passed freely into the canal. I then introduced
and secured with a T bandage a gum-elastic catheter, of about No. 9 size, having
its anterior end sheathed for an inch and a half or so with a tube of Berlin silver
to serve the double purpose of presenting a smooth surface to the divided
textures and conferring rigidity upon the portion of the flexible tube which
occupied the terminal part of the canal and that which projected beyond it,
so that it might be tied in with perfect security. The metallic portion was
also expanded at a short distance from its free end into a collar presenting
a concave surface towards the glans, to protect the new meatus from irritation
by the threads used for tying in the instrument. The catheter was made long
enough to reach back to the membranous part of the urethra, but not into the
bladder, in order to allow the patient control over his urine; and the eye was
terminal instead of lateral, to admit of free exit for the fluid. The antiseptic
arrangements were exactly as in the last case; that is to say, I trusted to the
ascertained physiological fact that the healthy urethra contains no fermentative
organisms ; and, after scrupulously cleansing the external integument with
1 to 20 carbolic lotion, conducted the entire operation under the spray, and
at its conclusion packed moist boracic lint around and over the organ, making
it especially substantial in the perineum, where the urine would flow down ;
and over this permanent dressing, which was fixed by stitches to the retaining
bandage, was arranged a movable portion, in the form of an apron, of boracic
lint, covered with thin macintosh ; a special nurse being provided to watch
the boy, and attend to him during acts of micturition, as in the former case.
The deep dressing was left untouched for five days, except that the patient
passed his water through it, and that boracic lotion was poured freely over it
after each occasion. When removed, it was found free from any ammoniacal
odour, and a similar dressing was applied without disturbing the catheter.
The second deep dressing was left untouched for another week, the boy mean-
while having lost entirely the pain in micturition of which he complained during
240 ON RECENT IMPROVEMENTS IN THE
the first few days ; and when the lint was changed, after being soaked for seven
days with urine, it was, like the first dressing, entirely free from ammoniacal
smell. The catheter being now removed, the meatus presented the appearance
of being completely cicatrized all round; but at one spot the surface, though
smooth, looked so delicate that I thought it prudent to apply one more dressing
as before, to protect the tender part from the irritation of putrid urine. The
catheter, however, was not reintroduced. Finally, on removing this last dressing
five days later, I found the epithelial lining of the meatus obviously firm and
sound throughout, and the orifice still freely admitted a No. 9 bougie. Thus,
during the five days in which the newly made canal had been left unsupported,
no contraction whatever appeared to have occurred—a result which seemed
to be explicable by the healing having taken place, as it appeared, without the
occurrence of granulation, so that the new tissue which had formed over
the raw surface was in so thin a layer that the effect of its shrinking was
insignificant.
Boracic acid may also be sometimes used with advantage in the form of
an ointment, for which I would advise the following mode of preparation :
Take of boracic acid, finely levigated, one part ; white wax, one part ; paraffin,
two parts ; almond oil, two parts. Melt the wax and paraffin by heating them
with the oil, and stir the mixture briskly along with the boracic-acid powder
in a warm mortar till the mass thickens. Then set it aside to cool, after which
it will be found to be a pretty firm solid mass, which is to be reduced to the
proper consistence of a uniform ointment by rubbing down successive portions
of about on ounce each in a cold mortar. This ointment, when used, is spread
very thin upon fine muslin or linen rag, which absorbs more or less of the almond
oil and leaves a layer of blended wax and paraffin, flexible at the temperature
of the body, and separable from the skin with the utmost ease by the discharge,
which is thus not at all confined by it, but diffuses itself and flows out beneath
it, receiving as it goes an abundant supply of the acid to prevent putrefaction,
while cicatrization is not materially interfered with by the mild antiseptic, and
still less by the perfectly bland wax and paraffin.
A good example of the value of the boracic ointment was presented by
a case of large rodent ulcer of the face lately under my care in the Edinburgh
Infirmary, and treated by excision. The disease involving a large extent of
the cheek, both eyelids, both nostrils, a considerable portion of the upper lip
and part of the lower one, it was impossible to cover the raw surface by a plastic
operation. It was therefore of great importance that efficient antiseptic means
should be employed ; for there is no more simple or more striking illustration of
the value of this principle of treatment than the entire absence of inflammatory
DETAILS OF ANTISEPTIC SURGERY 241
disturbance around an open wound when putrefaction is really prevented from
taking place in it; the ‘stimulus of necessity’ of John Hunter being, in truth,
simply the stimulus of putrefying substances, so that the danger which usually
attends open wounds is entirely avoided by efficient antiseptic measures.! sut
whatever might be the material employed for this purpose, it was inadmissible
to interpose a protective layer between it and the raw surface ; for this would
simply have had the effect of conducting septic fermentation over the entire
wound from the sources of putrefaction present at the mouth and nostrils.
Seeing, then, that the antiseptic must be applied directly to the divided tissues,
it was of course desirable that it should be as mild as possible consistently with
its efficiency ; and for a situation like this the boracic ointment was much
better adapted than the moist boracic lint, the fine cloth spread with it applying
itself with facility and accuracy to the irregularities of the surface, and keeping
its position without any retaining means except a packing of unprepared gauze
applied over it to absorb discharge, and retained by a bandage of the same
light material.
The eyeball, left bare by the operation, was protected from contact with
the dressing by having the loose skin above the upper eyelid drawn down over
it by means of the ‘ button suture ’, as I may term a form of ‘ stitches of relaxa-
tion ’,? which I have used for nearly two years with great advantage. It consists
of two oval pieces of sheet lead, about one-twentieth of an inch thick, with
a central perforation to receive a moderately thick silver wire. The silver wire
is first passed as an ordinary suture, except that it is carried at an unusually
great distance from the edge of the wound, both as regards surface and depth ;
each end of the wire is then passed through the hole in the corresponding lead
button, and secured by being wound once round the shorter diameter, as shown
in the accompanying sketch (p. 242). Thetwo buttons thus take the place of the
tips of two fingers of the two hands in giving support to the deeper parts of the
wound, while leaving the cutaneous margins entirely free ; and when the wound
is at all extensive several pairs of buttons are applied in this way, constituting
a sort of interrupted quilled suture. By their means the lips of a wound which
otherwise could not be got to meet without considerable tension will often lie
1 To this statement it is necessary to make an exception with regard to erysipelas, which I have
known to appear in some surgical patients from whose wounds, as far as I was able to judge, all fermen-
tative agency from without had been excluded. But, except during an epidemic of this disease, such
as prevailed in Edinburgh about two years and a half ago along with a virulent outbreak of small-pox,
the chance of its occurrence under strict antiseptic management is so small that it scarcely needs to be
taken into consideration.
* The importance of special stitches of relaxation—‘ Entspannungs-Nahte '"—was, so far as I am
aware, first pointed out by Professor Simon, of Heidelberg, in his important work on vesico-vaginal
fistula.
242 ON RECENT IMPROVEMENTS IN. THE
in contact of their own accord, any number of superficial sutures being added
that may seem desirable to keep the edges of the skin in accurate apposition with
a view to primary union.
The larger the surface which the buttons present to the skin the greater
is their hold upon it, and the less, consequently, is their liability to glide and
allow the wire to cut through the tissues by ulceration. When the circumstances
of the wound allow them to be used as large as they are represented in the sketch,
as after removal of the mamma, it will probably be found, when they are removed
after the lapse of a week or ten days, that the buttons still occupy precisely
the same situations that they were originally placed in, the surface beneath
them being slightly depressed, but, in consequence of the diffusion of the pres-
sure, not ulcerated, and this even in cases in which, a large amount of skin
having been sacrificed, they have been made to exercise a degree of traction
which without experience would seem inadmissible. But much smaller buttons,
though less perfect in their action, will often be found of great value in small
wounds, as, for example, after the operation for hare-lip, where they take the
place of strapping, but work much more effectually and also much more con-
veniently, as they leave the cutaneous margins free from compression and open
for inspection. Here, indeed, at the upper part of the wound the small size
of the buttons is attended with little disadvantage, because, being applied to
the alae of the nose in planes nearly perpendicular to the direction of the wire,
which perforates the tissue deeply below the septum narium, they cannot glide
at all upon the surface, but, retaining their position perfectly, prevent in a very
satisfactory manner the stretching of the uniting tissue at the nostril which
is so prone to occur under strapping. In this particular situation, therefore,
the only disadvantage of the necessarily small size of the buttons is that, their
pressure being concentrated on comparatively small portions of the skin, they
DETAILS OF ANTISEPTIC SURGERY 243
will be liable to cause patches of superficial ulceration if the traction upon them
should become increased by inflammatory turgescence. But if this threatens
to occur, either in this particular wound or in any other, the difficulty is readily
got over by unwinding the wire from one of the buttons, and, after straightening
it, allowing the button to slip upon it to any degree to which the tension disposes
it, and then fixing it again by winding the wire round it. And, conversely, if
the support of the buttons is still required after they have become slack from
any cause, they can be braced up at pleasure to any requisite degree.
Even when the edges of the wound cannot be made to meet at all, the
extent of the exposed tissues and consequent granulating surface and cicatrix
may be greatly reduced by the use of the button stitches, as was illustrated by
the case of rodent ulcer which we are considering, where a single pair of buttons
being applied, one to the skin above the eyelid and the other to that over the
lower border of the jaw, the connecting wire lying exposed on the raw surface,
the integument thus drawn down formed a permanent covering for the eyeball.
To return to the effect of the antiseptic dressing in this case. It was
beautiful to witness the entire absence of inflammatory disturbance in this
large open wound, involving such exquisitely sensitive parts, the surrounding skin
remaining free from day to day from any inflammatory blush or puffiness, and
the patient experiencing absolutely no uneasiness after the smarting? which
immediately followed the operation had subsided, as it did within a few hours
of its performance. On the changing of the dressing, which was done daily
during the earlier periods, the entire mass came off like a mask, without adhering
in the least to the wound, while there was no accumulation whatever of the
discharge, which constantly passed freely out into the porous mass arranged
to absorb it; and there was never observed the faintest putrefactive odour.
Cicatrization also proceeded satisfactorily from all parts of the edges of the
wound, and it was an interesting circumstance that, while the epithelial ring
which was thus formed had, in the greater part of its extent, the denseness and
opacity of an ordinary scar upon the skin, the portions in the vicinity of the
upper lip and nostrils had a peculiar delicacy and transparency, allowing redness
of the subjacent vascular structures to show so distinctly that, except for their
smoothness and dryness, these parts of the cicatrix might have been mistaken
for unhealed granulating surface. The explanation obviously was that the
epithelial formation, taking place only as the offspring of pre-existing epithelium,
partook of the character of that from which it grew, having the density and
' This smarting was probably chiefly due to the effect of the solution of chloride of zinc, which,
as an additional precaution, I had applied to the parts of the wound in the immediate vicinity of the
mouth and nostrils.
244 ON RECENT IMPROVEMENTS IN THE
opacity of epidermis when it sprang from the edges of the skin, but possessing
the delicacy of the epithelium of the interior of the lip and nostril when, the
skin of those parts having been all removed, cicatrization proceeded from the
margin of the mucous membrane. Ultimately there was about one inch in
breadth of the lower portion of the scar which presented these peculiar characters;
and the mucous cicatrix would doubtless have been more extensive had I not
supplied centres of epidermic growth over the general surface of the sore by
skin-grafting.
The mode in which this was done deserves a moment’s notice. As cicatriza-
tion was proceeding so satisfactorily under the boracic ointment, I thought
this application might perhaps prove not inconsistent with the preservation of
the vitality of skin grafts, so that the advantage of the procedure might be
obtained without putrefaction occurring in the sore, as would be the case if
the surface were covered with protective. I accordingly conducted the little
operation in the manner that has been described in an earlier part of this paper,
except that as each graft was laid down I placed upon it a morsel of the fine
rag spread with the ointment, a general piece being afterwards applied over all
to cover in the whole sore. But, to my disappointment, it turned out that not
a single graft took. The ointment, though so mild in its action as not to prevent
cell growth from epithelium which retained its connexions with its living neigh-
bours, was yet too strong for the portions of epidermis which were weakened
by isolation, and, before they had time to unite with the granulating surface,
operated upon them as an irritant or as a caustic. I therefore repeated the
process with this difference, that each graft, when placed upon the sore, was
covered with a very small square of the oiled silk protective dipped in boracic
lotion, and over this a rather larger square of the fine cloth spread with the
ointment, a large piece being afterwards applied to cover the whole. Thus each
graft was protected from the direct action of the boracic acid in the ointment,
while the bits of protective were everywhere so overlapped by the antiseptic
layer as to prevent putrefaction from entering. The result of this procedure
was that every one of the numerous grafts adhered, and the healing of the sore
proceeded to its completion with much greater rapidity, and I believe with
much less contraction of the scar, than would otherwise have been the case.
In plastic operations such as those for the repair of the lower lip, the deeper
edges of the wound communicating with the buccal cavity with its septic contents,
any sort of antiseptic treatment may at first sight seem altogether out of place.
But the primary union between the cut surfaces, which may be reckoned on
almost as a matter of certainty if the operation has been so conducted that the
edges of the wound can be brought together without tension, prevents the
DETAILS OF ANTISEPTIC SURGERY 245
spread of putrefactive fermentation outwards from the saliva and buccal mucus.
For it would appear that the living tissues of the cut surfaces, provided that
their vital energies are not impaired by inflammatory disturbance, operate
upon a thin layer of blood or lymph (fibrine) between them in the same sort
of way as the mucous membrane of a perfectly healthy urethra acts upon the
mucus or residual urine contained in it, as before alluded to in connexion with
the case of hypospadias: that is to say, the healthy living tissues prevent the
development of septic organisms in their immediate vicinity ; and this I believe
to be the explanation of the possibility of primary union without antiseptic
treatment. Thus the process of primary union is a sort of natural antiseptic
arrangement so far as the materials between the cut surfaces are concerned ;
and hence it is quite reasonable to employ external antiseptic means after a
plastic operation in such a situation. And, in point of fact, it will be found
well worth while to apply a strip of fine rag spread with boracic ointment
sufficiently broad to cover the lips of the wound and the points punctured by
the sutures, retaining it in position by a somewhat broader strip of unprepared
gauze, with its edges glued down with collodion. The result is that, the surface
being kept moist and at the same time free from putrefaction, the occurrence
of the troublesome pustules which are so often seen under scabs in the line of
incision or about the stitches is prevented, and the union along the cutaneous
margins, which it is so important to secure, is attained with much greater
certainty and perfection. The ointment should not be applied till oozing of
blood has ceased; and until this has occurred, the wound is kept covered with
a piece of boracic lint.
I need hardly remark that to operate under the spray when the wound
communicates with the septic buccal cavity would be an absurdity. The use
of carbolic lotion should also be avoided, on account of the irritation which it
occasions to the tissues. There is, however, no objection to having the sponges
rendered pure by wringing them out of the mildly acting boracic lotion.
In operations of this kind silver wire for the deeper stitches and horsehair
for the superficial ones answer extremely well; the rigidity of the wire enabling
it to give valuable support, while both these kinds of material are mechanically
antiseptic, since they afford no nidus for putrefactive fermentation in their
substance, and both are so smooth in surface as to be in that respect quite
unirritating. For microscopic examination of horsehair shows that its external
epithelium, unlike the imbricated arrangement which prevails in many hairs,
such as those of the mouse or of the human head, is so arranged as to produce
perfect smoothness, a circumstance which is probably further valuable from the
facility with which adhering dust can be removed.
246 ON RECENT IMPROVEMENTS IN ANTISEPTIC SURGERY
One other use of the boracic ointment remains to be mentioned—namely,
as a substitute for oiled silk protective in cases attended with inevitable putridity
of the discharge from the interior of the part concerned ; as, for example, after
excision of a joint on account of caries attended with sinuses, where the injection
of chloride-of-zinc solution has failed to eradicate the septic condition of the
interior. Under such circumstances, though it is not possible to prevent
putrefaction, it is very desirable to mitigate it, both for the sake of the part
itself, and still more in order to avoid as much as possible the contamination
of the atmosphere of the ward or sick chamber. But if oiled silk protective is
applied beneath the antiseptic gauze, or dry boracic lint employed, the putre-
faction present in the pus effused beneath it will continue to advance unchecked ;
and unless the dressing be changed daily, the oiled silk will acquire a very foul
and irritating character. And even a dressing of wet boracic lint applied next
the wound and covered with gutta-percha, though it answers the purpose much
better, may become very putrid in the course of forty-eight hours, in conse-
quence of the pus accumulating beneath it and so eluding the action of the acid.
But if a piece of fine cloth spread with the boracic ointment is substituted for
the protective, the discharge, compelled to diffuse itself in a thin layer beneath
the ointment, continually receives from it a supply of the acid, which corrects
more or less its original putrefaction ; and the result is that after the lapse
of two or even three days, the fetor is much less than it is in twenty-four hours
under oiled silk protective or water dressing ; and thus, while the atmosphere
of the apartment is kept comparatively pure, the patient and the surgeon are
saved the disadvantages of needlessly frequent dressing.
AN ADDRESS ON THE EFFECT OF THE ANTISEPTIC
TREATMENT UPON THE GENERAL SALUBRITY
OF SURGICAL HOSPITALS
Delivered in opening the Surgical Section of the British Medical Association in Edinburgh, August 4, 1
075
[British Medical Journal, 1875, vol. ii, p. 769.]
GENTLEMEN.—I believe I can hardly more profitably occupy the time
allotted to me for an address in opening this section, than by bringing before
you some facts illustrative of the effect of antiseptic treatment, when strictly
carried out, upon the general salubrity of surgical hospitals.
Six years ago, when writing on the very remarkable improvement which
had been brought about by ‘ enforcing strict attention to the antiseptic principle ’
in the wards of which I had charge in the Glasgow Royal Infirmary, ‘ converting
them from some of the most unhealthy in the kingdom into models of healthi-
ness, I ventured to express myself thus: ‘Considering the circumstances of
those wards, it seems hardly too much to expect that the same beneficent change
which passed over them will take place in all surgical hospitals, when the principle
shall be similarly recognized and acted on by the profession generally.’? That
prediction, I think I may say, is now in course of fulfilment.
I shall speak first of what has come to my knowledge with regard to some
foreign hospitals, and I will begin with Copenhagen, where Professor Saxtorph
long ago introduced antiseptic treatment ; indeed, I believe he was the first
to bring it into operation on the Continent. The large hospital of which he
had the charge used to be a very unhealthy one. Pyaemia was extremely
frequent, even after very small operations, such as amputation of a finger.
Pyaemia has vanished ever since the antiseptic treatment was introduced,
hospital gangrene has almost entirely disappeared, and erysipelas is nearly
unknown except as imported from the town. Professor Saxtorph writes to me
as follows: ‘If you ask me what I have observed respecting the effects of
antiseptic treatment, I may say that it has not modified, but completely changed
my principles of pathology and my surgical practice. ... The word hosfitalism,
which some years ago found its way from Edinburgh to the Continent, no longer
terrifies us ; it no longer keeps us from performing operations in the infirmary,
and you seldom meet with a case that could be called a case of hospital disease.’
* See Lancet, January 8, 1870 (see p. 123 of this volume).
248 AN ADDRESS ON THE EFFECT-OF THE ANTISEPTIC TREATMENT
After going into details regarding the various forms of hospital disease, he
proceeds to describe the greatly increased success that now attends the treatment
of some injuries. ‘As to accidental deep wounds, large lacerated wounds of
the scalp, contused wounds with smashing of hand or foot, compound fractures
or wounds of joints, I almost invariably have them heal without any bad
symptoms, by means of antiseptic dressing and drainage-tubes. Any case of
this sort will almost certainly recover if there is no complication of shock, or
gangrene of the limb, or contusion of internal organs.’ He next speaks of the
change which has taken place in the results of operations, such as amputations
and excisions, and adds, ‘In short, I think I am right in saying that patients
very seldom die from an operation. If they do die, it is not the operation that
kills them, but the disease that existed previously to the performance of the
operation.’ Lastly, he alludes as follows to abscesses connected with diseased
bone. ‘ What until the last few years proved the most difficult to deal with,
are the abscesses which are connected with bone-disease. But now I think
we may safely cut into them, if we only persevere in the antiseptic treatment
for a sufficiently long time. By means of careful dressing, drainage-tubes,
and the antiseptic spray whenever the dressing has to be changed, we get over
those accidents of septicaemic poisoning which formerly almost invariably
followed incision into these collections. But I am equally sure that, if I do
not carry out the antiseptic treatment to its full extent, it is of no use whatever
to apply carbolic acid to a wound, at least as regards the dangers that always
accompany putrefaction.’
I come now to what I witnessed in the course of my recent travel in Germany,
and I shall speak only of those hospitals into which antiseptic treatment has
been introduced. Of these, the first I saw was Munich. The large Allgemeines
Krankenhaus there has been until lately increasingly unhealthy ; pyaemia was
very frequent ; and hospital gangrene, which made its appearance in the year
1872, had become annually a more and more frightful scourge, until last year
it had reached the astounding proportion of 80 per cent. of all wounds that
occurred in the hospital, whether accidental or inflicted by the surgeon. And
not only was it thus extremely frequent, but was in a very severe form, produced
frightful ravages, often caused death, and led to patients who recovered being
retained an inordinately long time in the hospital. But, from the time when,
at the beginning of the present year, efficient antiseptic treatment was brought
into operation by Professor Nussbaum, they have not had one single case of
hospital gangrene. At the time when I was at Munich, they were doubtful
whether they had had one case of pyaemia ; erysipelas, formerly very prevalent
and severe, was rare, and, when it did occur, was in a very mild form; and
UPON THE GENERAL SALUBRITY OF SURGICAL HOSPITALS 249
I saw the convalescent wards—which previously had always been filled and
overflowing—standing one after another empty, because the patients, no longer
affected with hospital gangrene, recovered much more rapidly.’
I next proceeded to Leipzig, where Professor Thiersch is clinical teacher.
He has three hundred beds under his own charge, of course seconded by able
assistants. Professor Thiersch was the first to introduce antiseptic treatment
on scientific principles into Germany. His results, as regards the general
salubrity of the hospital, have been, on the whole, progressively more and more
satisfactory, and in the present year he was able to state that he had only had
one case of pyaemia in twelve months; and that, you will observe, in a service
of three hundred beds. Hospital gangrene, also, had almost disappeared.
There had been in 1871 a curious attack of that disease in two barrack wards,
which seemed to be due to old hospital furniture piled up in an empty space
under those apartments ; but of late this also has vanished. Professor Thiersch
has of late used, instead of carbolic acid, salicylic acid as an external dressing ;
but he still employs carbolic acid for the spray and lotion. Salicylic acid, as
he uses it, certainly works very well; but that his increasingly satisfactory
results are due to any special virtues of that agent cannot be maintained.
From Leipzig I passed to Halle, where I found Professor Volkmann carrying
* Since the delivery of this address, I have received from Professor Nussbaum a pamphlet entitled
Die Chirurgische Clintk zu Miinchen im Jahy 1875: Ein Andenken fiir seine Schuler. Published by
Ferdinand Enke, Stuttgart. The subject of this work is the complete revolution brought about in the
salubrity of the hospital by antiseptic treatment, and the means by which this result has been attained.
One passage from the first chapter seems to me to demand reproduction here. After describing the
previous frightful state of unhealthiness, he says: ‘ Everything that we had tried against the above-
mentioned horrors had proved unsuccessful. The open treatment, the occlusion dressing, the con-
tinuous water-bath, irrigation with chlorine water or with carbolic-acid solutions, salicylic acid in powder
and in solution, the putting on of Lister’s antiseptic materials—carbolic paste, &c.—all, all were unable
to combat hospital gangrene and pyaemia. But when in the course of a single week, with great energy
and industry, we applied to all our patients the newest antiseptic method, now in many respects improved
by Lister, and did all operations according to his directions, we experienced one surprise after another.
Everything went well; not a single other case of hospital gangrene occurred. Pyaemia and erysipelas
were observed a few times at the very beginning ; but only, as the result proved, because we did not yet
possess the necessary practice in the carrying out of Lister’s directions. | We took pains, as you know,
and learned from day to day more exactly how to comply with his instructions. Ourresults became better
and better, the time of healing shorter, and pyaemia and erysipelas completely disappeared’ (op. cit., p. ©).
* The true explanation of the improved results is given by Professor Thiersch himself in the following
passage in a work which he has recently published on this subject—a statement characterized by the
usual perfect candour of the distinguished writer: ‘Our results have constantly improved in proportion
to the perfecting of the method and our own practice in carrying out its details, They are, indeed,
not so good as those of Lister himself, or of Volkmann, &c.’ (see Klinische Ergebnisse der Lister schen
Wundbehandlung, &c., one of the Klinische Vortrdge edited by Volkmann; Leipzig, 1875, p.645). To
the same cause, I have little doubt, is to be attributed the fact that erysipelas was considerably less
(‘bedeutend geringer,’ op. cit., p. 676) in the year 1874 than in the previous year. Professor Thiersch
himself believes that erysipelas is not influenced by antiseptic treatment; but this view is entirely
opposed to the experience of Saxtorph and Nussbaum already mentioned in the text, and to that of
others to be alluded to in the sequel.
LISTER II S
250 AN ADDRESS ON THE EFFECT OF THE ANTISEPTIC TREAIMENT
out antiseptic treatment just in the same way as we do here. He gave an
antiseptic demonstration, to which he invited professors from various parts of
Germany ; and he certainly showed us a magnificent set of cases. It was,
I confess, somewhat gratifying to me that Professor Volkmann had obtained
his results without any of his assistants having visited Edinburgh. Seeing the
importance of the subject, he had worked in good earnest at the system, in
accordance with what he had read of my writings. He told me he had only
gradually got into the way of carrying out the system properly ; but I had
the satisfaction of seeing everything done exactly as we do here, and with results
of the most brilliant kind. That hospital was previously an extremely unhealthy
one. The wards are small and overcrowded; each one has a water-closet
opening into it, and a large drain of the city runs under the wards. Indeed,
the building is so confessedly bad, that it has been condemned to demolition.
Pyaemia used to be exceedingly common there; but, since the introduction of
antiseptic treatment, a change has taken place which I can best describe by
a quotation from a paper by Professor Volkmann himself? :—
‘I had hoped to have been able to publish before now the communication
which I made on the antiseptic treatment and Lister’s mode of dressing, on
the occasion of the third Congress der deutschen Gesellschaft fiir Chirurgie ;
but as this has, unfortunately, not been the case, I may, perhaps, be allowed
to mention here a few facts for the purpose of showing how greatly the danger
of some forms of injury, which were formerly followed by a very high rate of
mortality, is diminished by this procedure.
“Since the introduction of the antiseptic method into my clinique, now
exactly two years ago (at the end of November 1872), no single patient suffering
from a compound fracture, in which conservative treatment was attempted,
has died. Amongst this number are included even those cases in which con-
servative treatment was only resorted to because the patients would not give
their consent to amputation, and also those in which we at first underestimated
the severity of the injury, and afterwards intermediate or secondary amputation
had to be undertaken on account of haemorrhage or gangrene. The number
of compound fractures successfully treated without a single fatal result in our
hospital, which is old and always overcrowded, and offers the most unhealthy
hygienic conditions, amounts at present to thirty-one. Amongst these were
as many as nineteen compound fractures of the leg, in several instances much
comminuted, and often complicated with most severe bruising and laceration
of soft parts. There were also two compound comminuted fractures of the
patella, both of which recovered with movable joints. No case of pyaemia has
occurred for a year and a half—i.e. since July 1873—although during this
period alone about sixty major amputations have taken place.’
I also learn that hospital gangrene is now entirely unknown in that hospital.
Erysipelas likewise is extremely rare; and, where it does appear, it is of a
* See Professor Volkmann on Antiseptic Osteotomy, translation in Edinburgh Medical Journal, March 1875.
UPON THE GENERAL SALUBRITY OF SURGICAL HOSPITALS 251
superficial and mild type ; and Professor Volkmann told me that his experience
of the effects of antiseptic treatment in diminishing the amount and severity
of that disease was so striking, that he entirely differed from the opinion of
Professor Thiersch on this matter.?
Amongst the cases brought before us in Professor Volkmann’s demonstration
was one of excision of the hip-joint, where putrid sinuses had existed before the
operation. About a week had passed since the operative procedure, but there
was no purulent discharge whatever ; and no fluid even of a serous character
could be pressed out from the small spot that alone remained unhealed, and the
use of a drainage-tube had been already given up. In short, the case had
followed the typical course we expect under antiseptic treatment when we
operate with an unbroken skin. This is a kind of result I myself had never
yet obtained, and it filled me with astonishment. I inquired how it had been
arrived at, and I found it was as follows. Professor Volkmann several years
ago strongly advocated the application to diseased soft parts of ‘the sharp
spoon’ which had been introduced into German surgery by Bruns, of Tiibingen,
for scraping carious bone. Thus, supposing a strumous abscess to be opened,
instead of leaving the degenerated textures around to come away by a tedious
process of suppuration, or to be removed by slow absorption, he scraped it all out
at once with the sharp spoon, and thus greatly accelerated the recovery. Being
thus accustomed to the use of this instrument, he applied it to clear out the
pyogenic membrane of putrid abscesses and sinuses, and all granulations around
the diseased bones after excision. For my part, I have always, after operating
upon such a case, treated the cut surfaces with solution of chloride of zinc, and
injected the sinuses with the same, in the faint hope of exterminating existing
putrefaction ; but I have practically never succeeded. The failure was always
readily intelligible to me, on the ground that I could never get the antiseptic
to penetrate all the recesses of the sinuses and the lymph or sloughs lying among
the granulations. But here Professor Volkmann had cleared out the offending
substances altogether, and then introduced an antiseptic lotion; and he told
me, to my amazement, that it was the rule with him to attain results of the
character I then witnessed. If my journey on the Continent had been one
of unmixed labour, I should have thought that labour well rewarded by this
circumstance in my visit to Halle. I have already put this plan in operation
in my own practice since my return, and I hope to show you some of the results
to-morrow, at a demonstration in the operating-theatre of the Royal Infirmary.
Whether I can obtain such frequent success as Professor Volkmann, I do not
know ; but I have already succeeded in some cases.
* See note at the foot of page 240.
S2
252 AN ADDRESS ON THE EPFECT OP THE ANTISEPTIC TREATMENT
In Berlin, Professor Bardeleben, with one hundred beds under his care
at the Charité Hospital, has long introduced the antiseptic system. The hospital
used to be a very unhealthy one. Pyaemia was so frequent, that amputation
in the lower limb was almost certain death to the patient ; but, through anti-
septic treatment, this has for a long time past been entirely changed. Professor
Bardeleben informed me, at the time of the meeting of this Association in
London, that pyaemia was practically abolished from the wards, without any
other change than the introduction of antiseptic treatment ; and I found that
this same satisfactory condition of things continued at the time of my visit
this year. Erysipelas was also rare, and of a mild type; and hospital gangrene
very uncommon. At the same time, I feel bound to express my conviction
that Professor Bardeleben would get still better results had he not been led,
on the score of economy, to substitute for our antiseptic gauze unprepared
gauze soaked with a watery solution of carbolic acid; for here, the carbolic
acid being dissolved in a liquid, instead of being stored up in an insoluble medium,
the antiseptic and its vehicle are both displaced together by the discharge which
soaks into the dressing, and this involves great additional risk. In fact, Professor
Bardeleben told me that for very special cases he still used our antiseptic gauze.
In the other great clinical hospital of Berlin, the renowned and veteran
surgeon Von Langenbeck had not until the present year seen his way to adopting
antiseptic treatment. He had professed admiration of various results he had
heard of ; but, as Professor Bardeleben said, it had been barren admiration.
But it was a singular coincidence, and one very gratifying to me, that, when
I called upon him, I found him preparing to perform his first operation according
to strict antiseptic principles. The case was one of tumour of the upper end
of the fibula; and, considering the possibility of the wound communicating
with the knee-joint, he felt himself bound to use antiseptic treatment. This he
did with perfect faithfulness, in spite of the serious inconvenience of a most
unnecessarily wetting spray ; and, when the operation was concluded, he did
me the honour to ask me to put on the dressing.
At Magdeburg, I found a great hospital, containing, on the average, one
hundred surgical patients. This hospital used to be noted for its unhealthiness ;
but I learned that, since the introduction of antiseptic treatment, an entire
change had come over it in this respect. Pyaemia has almost entirely dis-
appeared, hospital gangrene has gone, and erysipelas, when it occurs, is of
a very mild type.?
* Dr. Hagedorn, the chief surgeon, was absent at the time of my visit; but in a letter, which,
through accidental circumstances, I did not receive till after this address was delivered, he describes
in full detail the change that antiseptic treatment has effected. From this letter I must content myself
with quoting two short passages. ‘I have now been for twelve years chief surgeon to the hospital
UPON THE GENERAL SALUBRITY OF SURGICAL HOSPITALS 253
At Bonn, also, I heard similar testimony. I learned from Professor von
Busch, who introduced antiseptic treatment into the clinical hospital last year,
that some previously unhealthy wards had since quite changed their character ;
and that in some fine airy wards, which were always very free from hospital
disease, the mode of healing of the wounds was something altogether different
from what it used to be.
So much, then, gentlemen, for my continental experience. And now
I wish to say a few words as regards the infirmary here, where I have now been
at work for about six years. And, first, as to the conditions under which I am
working. The wards, as some of you have seen, are small and overcrowded.
These wards were never so severely tested as they have been since I came here.
There used to be, in the old High School building, two reserved wards kept
ready for the reception of erysipelas or other peculiar cases ; but, at the time
when I was appointed, twenty beds were taken off from the clinical surgical
department for the purpose of creating a new surgeoncy; and, at the same
time, the two reserved wards previously kept empty were filled with patients.
That particular block of building has, therefore, been more severely tried than
ever it was before. The number of beds is so limited that there is always great
pressure upon them. When I came to Edinburgh from Glasgow, seeing the
beds so close, I had several of them cleared out ; but the result was, I found,
that the same number of patients were admitted; and there always being a
considerable proportion who could walk about during the day, they were put
down on mattresses on the floor at night, so that the number of patients remained
as before ; and, as the wards continued perfectly healthy, I had the beds reintro-
duced. But, more than this, I have still the mattresses on the floor. If you
were to go into these wards sometimes at night, you would be surprised to see
how many “ shake-downs’ there are. We have, also, often two or three children
in one bed; and altogether by these means, while I have fifty-five beds, I have
lately had seventy-one patients. During the time I have been here, there has
hardly been a day on which there have been as few patients as beds, although
any of you can see that those beds are not as distant from each other as they
ought to be, according to modern notions of what is requisite for the salubrity
of a hospital.
Then there is another important respect in which my wards have been
and I had to do battle on a large scale with pyaemia and septicaemia, till in May 1872 I introduced
your antiseptic method.’ ‘ Since that time we have constantly practised it with excellent results, which,
in truth, have been constantly improving ; for at first the procedure does not always succeed, and every
man must pay for his schooling (muss Lehrgeld geben). Now I have arrived at the conviction that
your procedure is unconditionally secure, and that in every failure the surgeon himself is to blame, and
not the method.’
254 AN ADDRESS ON THE EFFECT OF THE ANTISEPTIC TREATMENT
more severely tried than before. \There had previously always been an annual
cleaning of the wards of our infirmary. Now, this involves considerable incon-
venience. The patients had to be transported to another part of the hospital,
and some cases were liable to be injured by this transport. Therefore, when
the annual cleaning came about, I used to consider whether the patient would
get more harm from the want of the cleaning of the wards, or from the trans-
portation. I thought they were more likely to get harm from the transport ;
and this being year after year my conviction, it is now three years since any
cleaning took place in these wards of mine.) The year 1872 was the last in which
it was practised, except in the case of one individual ward where a sore throat
prevailed last summer, which seemed to be of the nature of scarlatina, and on
that account the ward was emptied and purified. I have sometimes observed
remarks made with regard to the results of treatment in my wards, to the effect
that I work under superior hygienic conditions. It is, in truth, exactly the
opposite. My wards, in these respects, are more severely tried, I believe, than
those of any other surgeon in the kingdom.
Then it is said that greater cleanliness is involved in the antiseptic treat-
ment. This, again, is an entire mistake. If we take cleanliness in any other
sense than antiseptic cleanliness, my patients have the dirtiest wounds and
sores in the world. I often keep on the dressings for a week at a time, during
which the discharges accumulate and undergo chemical alteration, probably
from oxidation and the action of the resin of the gauze upon them ; and, when
the wounds are exposed after such an interval, the altered blood with its various
shades of colour conveys often both to the eye and to the nose an idea of
anything rather than cleanliness. Aesthetically they are dirty, though surgically
clean.
There is yet another way in which my wards have been unusually tried—
namely that I now perform operations which, without antiseptic means, I should
not have considered justifiable, some of them being of a character which used
to involve especially the risk of pyaemia, such as cutting down on ununited
fractures of the femur, and removal of the ends of the fragments.
Yet, in these circumstances, if I have had one case of pyaemia where I have
operated myself, it is the only one I know of; and that was a spurious form
of the disease. It occurred in a patient from whom I had removed the mamma,
and, at the same time, cleared out all the axillary glands; and putrefaction
took place in the axilla, in consequence, as we had reason to believe, of mis-
management of the spray. Of hospital gangrene we have not had one single
case during these six years. As regards erysipelas, our experience has been
various. Asa rule, it is very rare in my wards. I have been two entire years
UPON THE GENERAL SALUBRITY OF SURGICAL HOSPITALS 255
without a single case of it; but, on the other hand, there was a time when it
was frequent. This was during a concurrent epidemic of small-pox and erysipelas
in Edinburgh two years ago. The erysipelas was of a very virulent type, and
some patients in private practice in the city died of erysipelas affecting the
puncture of revaccination. At this time we had several cases of erysipelas
admitted into my wards from the town, and several, also, took origin within
the hospital. But the constitutional rather than the local cause of these cases
was shown in several instances by the disease occurring not in or near the wound,
but at some remote part, as in the head after an operation upon the penis. And
it was somewhat remarkable that in no case did the disease as it originated
in the hospital assume the malignant form which it sometimes exhibited in
private practice.
Tetanus also appears to be rendered much less frequent by antiseptic
treatment. Far be it from me to say that putrefaction is the only cause of it ;
we all know it is otherwise ; but when I say that, in six years, with an average
of sixty severe surgical cases, I have only had two cases of the disease, and
those both of them in connexion with septic wounds, I show strong grounds
for believing that, if we exclude putrefaction, we exclude one—and the most
common—exciting cause of tetanus.
One objection that has been urged against my treatment is the inordinate
length of time patients remain in hospital. No doubt it is so in some cases ;
but, as a rule, these are instances in which we expect to cure otherwise incurable
cases, Such as spinal abscess. But, on the other hand, on comparing Mr. Syme’s
case-books with my own, during two periods of three years, the unexpected
result has lately been arrived at that, in proportion to my number of beds,
I have had a larger number of operations than Mr. Syme ; showing that, while
some patients, kept alive by antiseptic treatment, have remained long in the
hospital, this was more than counterbalanced by the rapid cure of others.
I trust, gentlemen, that the facts which I have now had the honour to bring
before you will be considered pretty strong proof of the value of strict antiseptic
treatment in promoting the general salubrity of surgical hospitals.
DEMONSTRATIONS OF ANTISEPTIC SURGERY
BEFORE MEMBERS OF THE BRITISH
MEDICAL ASSOCIATION
[Edinburgh Medical Journal, vol. xxi, 1875-6, pp. 193, 481.]
DEMONSTRATION I
GENTLEMEN.—I propose this morning and to-morrow morning to avail
myself of such opportunities as happen to be at my disposal to illustrate before
the British Medical Association the methods and the value of antiseptic treat-
ment. The first case which I shall bring before you will show this treatment
in its simplest form, and in one of its most striking instances—a case in which
I propose to lay open the knee-joint. The patient (a man fifty-four years of age)
was under my care some years ago, with a very large effusion under the deltoid,
in an acute form, attended with much fever. I opened it antiseptically, and
the patient made a rapid recovery without suppuration. He has thus already
had experience of the value of antiseptic treatment, and therefore trusts it
implicitly for the management of what he at present suffers from, namely,
painful effusion into the knee-joint. It is of twelve months’ duration, and has
resisted repeated blistering (about a dozen have been applied in all), and from
the peculiar prominence that exists over parts of the articulation, I suspect
suppuration is imminent. Now, if blistering failed in a case of this kind, without
antiseptic management the surgeon would be at a loss what to do. Dieulafoy’s
aspirator might sometimes prove serviceable, but those who have tried it must
confess that they are often disappointed in consequence of the fine tube becoming
blocked by portions of lymph. But by antiseptic means we are able to obtain,
by incision and drainage-tube, a perfectly free exit for the fluid, and thus
relieving the joint altogether from the tension due to effusion, permit the natural
tendency to recovery to come into operation. I need hardly remark, that to
do this without antiseptic treatment would be madness—would be a thing
which no surgeon would be justified in doing ; to make a free incision into the
knee-joint and to keep the wound open with a drainage-tube, would be an
altogether unwarrantable procedure. We all know that the knee-joint has
often been opened by free incision for the extraction of loose cartilages, and that
in some such cases, the wound having healed by first intention, all has gone on
well without any antiseptic treatment at all; though we know also that this
DEMONSTRATIONS OF ANTISEPTIC SURGERY 257
is a very uncertain and dangerous practice. But though it is true that wounds
of joints, whether accidental or intentional, may heal without disturbance under
ordinary treatment, yet it is certain, that if such wounds were kept open without
antiseptic means, disastrous consequences would be inevitable ; by keeping the
wound open we should take away the only chance there would be, without
antiseptic treatment, of the case ending without disaster. But, Gentlemen,
paradoxical as it may at first appear, with antiseptic treatment the more free the
wound, and the more widely it gapes, the more certain you are to avoid inflam-
matory disturbance in the joint ; simply for this reason, that you are the more
certain of a free discharge of the plasma effused into the interior. And if you
avoid all tension from this cause, and at the same time exclude putrefactive
mischief, you have the joint left absolutely free from irritation. Before we
bring the patient in, I may say that I shall make the incision pretty free as
regards the skin, and carry it gradually down to the joint, so as to be able to
see and secure any small artery that may be divided. For if you simply plunge
the knife into the joint, and put in a drainage-tube, bleeding may take place
into the articulation from some deep vessel, and lead to considerable inconveni-
ence. Just as in Professor Andrew Buchanan’s well-known experiment, hydro-
cele fluid is made to coagulate by the addition of a little serum from a blood-clot,
so if a very little blood finds its way into the knee-joint, the liquor sanguinis
effused from the synovial surface mixing with the globulin of the red corpuscles
forms a coagulable fluid and undergoes coagulation, and you have the knee-
joint filled with solid matter, which interferes with the rapidity of recovery,
although in due time the accumulation disappears by absorption.
[The patient being now brought in, Mr. Lister proceeded|—Here, then,
we have before us the distended knee-joint. You observe this peculiar limited
special bulging, which, together with the history, makes me suspect that the
joint is on the eve of suppuration.
I have said that this case will be an example of the antiseptic treatment
in its simplest form. The antiseptic will not be introduced into the joint; it
will not be applied to the affected part at all. It will be merely employed
externally to prevent the access of septic mischief while we provide exit for
fluid from the interior. We shall first purify the skin with a strong (1 to 20)
watery solution of carbolic acid, which is best for detergent purposes ; water
holding carbolic acid but slightly, and very readily giving it up to act upon
anything else. Carbolic acid has a remarkable penetrating property. It blends
with oily substances and animal matters, and penetrates the hair and hair-
follicles, and therefore such a washing as I am now giving will render the skin
absolutely pure, surgically speaking. This is a very great point.
8 DEMONSTRATIONS OF ANTISEPTIC SURGERY BEFORE
i)
U1
In the next place, we shall have an antiseptic atmosphere provided by
means of this spray-producer, which acts on the principle of Siegle’s steam
inhaler. High-pressure steam, issuing by a minute orifice from a boiler heated
by spirit-lamp or gas, sucks up a strong solution of carbolic acid by a tube that
dips into a vessel containing it, and, blending with it in about equal quantity,
forms a I to 40 spray. We have lately very much improved our spray by
a slight alteration of the apparatus. We used to have the tube which conveys
the carbolic solution perpendicular to that for the steam, just as the air-tube
is at right angles with the water-tube in the common atmospheric odorator ;
and the result was a coarse spray with scattering drops, consuming a needless
quantity of the solution, and causing needless irritation of the surgeon’s hands
and wetting of his sleeves ; and, what was of more moment, inducing unneces-
sary irritation of the wound, and making around the trustworthy spray an
area of uncertain extent completely valueless, because the solution in it was
in the form of comparatively large drops with intervals of unaltered air. But,
by placing the tube for the solution at an angle of 45° with that for the steam,
and with its point ground off obliquely so as to be exactly in the axis of the
steam-tube, we get a spray destitute of scattering drops, perfectly trustworthy
throughout its visible extent, though little coarser than a London fog.
The slate on which I am now directing the spray is in an antiseptic atmo-
sphere; yet so fine is the spray, that it scarcely moistens the surface. The
face of one of my dressers is now enveloped by the cloud, which, as you observe,
is capable of being inhaled without serious inconvenience. That we should be
able to provide a respirable, yet reliably antiseptic atmosphere, is what I confess
I never anticipated. The boiler has a safety-valve to prevent explosion, and
a window to enable you to see when the water is becoming exhausted. A large
spray-producer like this will go on working, with one supply of water in the
boiler, for a couple of hours.
The part to be operated upon, then, being in an antiseptic atmosphere,
if the finger is to be introduced into the wound (and I shall very likely have
to pass my finger into the joint) you must take special care that it is an aseptic
finger; and this is done by cleansing it with an antiseptic solution, making
sure that it passes well into the folds of skin about the nail. Andif I should have
to introduce an instrument into the articulation, I must see that it is always
pure when inserted. In order, Gentlemen, that you may get satisfactory results
with this sort of treatment, you must be able to see with your mental eye the
septic ferments as distinctly as we see flies or other insects with the corporeal
eye. If you can really see them in this distinct way with your intellectual eye,
you can be properly on your guard against them ; if you do not so see them,
MEMBERS OF THE BRITISH MEDICAL ASSOCIATION 259
you will be constantly hable to relax in your precautions. I have seen, for
instance, a gentleman, anxious to carry out the antiseptic treatment completely,
take out a large loose cartilage from the knee-joint under the spray, using at
the outset instruments which had been purified by lying in a solution of carbolic
acid ; but in the course of the operation, I observed him take a pair of forceps
which seemed better adapted for his purpose than any which he had so prepared,
and simply dip them for an instant into the antiseptic lotion, and then plunge
them into the interior of the joint. Now, Gentlemen, was that doing the treat-
ment justice ? Between the teeth of those forceps there were probably portions
of dirt. Give the carbolic acid lotion time, and it would penetrate this dirt,
greasy though it might be; but it cannot do so ina moment ; and nothing was
more likely than that some portion of this dirt would come off from the forceps
and remain in the joint, and induce putrefaction there. I have known of a
gentleman with every anxiety to carry out antiseptic treatment, exploring
the wound in a case of fracture of the skull, and, the probe happening to fall to
the ground, it was taken up from the dusty floor, and immediately passed into
the depths of the wound. Now, Gentlemen, that was but courting failure.
What more likely than that some of the septic dust, which certainly was brought
up adhering to the bloody probe, should pass into the wound without having
been sufficiently acted on by the spray in the moment of transit, and, mingling
with the blood in the interior, be there protected for the future by the blood-
clots from the antiseptic influence of the dressings, and induce putrefaction ?
If we could see the septic material upon the instrument as distinctly as we
could see green paint in contrast with the red blood, then of course we should
say, We must wash off this green poison; but because we cannot see it with
the physical eye, we are always liable to make mistakes through neglect of using
proper precautions ; and I am more and more persuaded, the longer I practise
antiseptic surgery, that the chief essential to success is a thorough conviction
of the reality of the presence of the septic matter on all objects in the world
around us. Through the kindness of the President of the Physiological Section,
I hope to have the opportunity of demonstrating some facts which I believe
will tend to convince you that the septic ferments are, like those of the alcoholic
fermentation, living organisms—that they are analogous to the yeast plant.
But whether you believe or do not believe that they are living, it is as certainly
demonstrated scientifically as it is certain we are here, that these ferments do
exist. If we do not bear that in lively remembrance, we shall be constantly
making mistakes.
[Mr. Lister then proceeded to perform the operation. Some small arteries,
which bled in the incision, were secured with fine prepared catgut, and the
260 DEMONSTRATIONS OF ANTISEPTIC SURGERY BEFORE
joint having been opened, two drainage-tubes, each about 4-inch in diameter,
were inserted side by side; an obstructing band within the articulation being
divided by a probe-pointed knife guided by the finger so as to permit them
to be introduced fairly into the cavity. He commented on the various steps
as he proceeded, urging again the absolute necessity of having all the instru-
ments thoroughly aseptic, and went on to say|—One learns after a while to do
these little purifications instinctively, but at first it requires thought, intelligence,
and constant care, particularly to any one who has been in the habit of operating
without having to attend to these minutiae. Would that we could get rid of
all complications in the system! If we could dispense with the spray, no one
would rejoice more than myself; but until somebody wiser than I am can
supply some better means, we must continue to use it. There is, I find, con-
siderable thickening of the textures in the vicinity of the joint, and this is the
cause of the swelling which is still apparent, though the synovial capsule is
now empty. The outer orifices of the drainage-tubes are made transverse or
oblique, as required, in order that they may li flush with the surface of the
skin, and when retained in this position by means of the threads which you see
attached to their margins, they discharge their functions perfectly.
The operation having now been performed, the next point is so to dress
the wound as to make sure that nothing septic will get in before next dressing ;
this must be not a matter of hope but of certainty. The material which we
have used for some time past is an open cotton cloth, with the fibres impregnated
with a mixture of carbolic acid and common resin.’ Common resin holds carbolic
acid with extreme tenacity, and in consequence of this gives it off so slowly
as to be unirritating to the skin; yet at the temperature of the human body it
furnishes a sufficient supply of the acid for a trustworthy antiseptic dressing.
But at the ordinary temperature of the air in this country, the antiseptic is
evolved so slowly from the gauze that the fermentative energy of septic dust
is not at once extinguished by falling upon it, as it is by mingling with a strong
watery solution ; and if the gauze were applied dry, some active septic particle
adhering to its surface might enter the blood or serum at the outlet of the
wound, and propagate putrefaction to the interior. There was a time when
I used to have occasionally in my practice putrefaction which I could not explain,
but which I afterwards saw must be due to this cause, and the difficulty was
then at once overcome by dipping the lowest piece of gauze in a watery solution
of carbolic acid. This solution which I am now using, having been mixed with
blood from the wound, has a very dirty appearance. A surgeon, who went
* For details regarding the composition and mode of preparation of the antiseptic gauze, see Lancet,
March 13, 1875 (p. 210 of this volume).
MEMBERS OF THE BRITISH MEDICAL ASSOCIATION 261
round my wards some time since, expressed astonishment that I should use
dirty lotion to wash a wound, and to purify what I was placing upon it; but,
Gentlemen, the wound, although aesthetically dirty, was surgically pure, and
the lotion had not been made impure by being used for washing it. Even if
it had been otherwise, we might have trusted the carbolic acid to purify it.
Why then should we waste good lotion? I dip, therefore, in the lotion this
piece of gauze that I place next to the wound, and thus make perfectly sure
that nothing septic is applied to it.
It is most important that the spray be properly directed during the dressing.
I have seen a surgeon expose a serious wound, involving injury to the brain,
while the spray was only playing on the opposite side of the head. It were
far better that the antiseptic method should not be employed at all than that
it should be used imperfectly. For such attempts not only end in disappoint-
ment, but throw discredit on the system. Some people seem to say, ‘I have
tried the thing and failed, and therefore, of course, the system is all nonsense.’
I have seen it fail in my own practice, but under such circumstances I have
always thought there must have been some mistake on my part, and I have
endeavoured to discover where my mistake lay. But that does not seem to be
the way in which the matter is viewed by some of our professional brethren.
A small piece of gauze dipped in the lotion having been placed next the
wound, the dressing on which we rely for excluding putrefaction is applied in
the form of eight layers of the gauze, sufficiently broad, as you see, to cover the
surrounding skin for several inches in every direction ; and beneath the outer-
most layer is placed this piece of thin macintosh cloth to prevent the discharge
from going directly through the dressing ; because, if a considerable quantity
went through, strongly as the resin holds carbolic acid, it might be all washed
out before twenty-four hours had elapsed, and then putrefaction would spread
inwards to the wound. The dressing is secured by a bandage, for which strips
of the antiseptic gauze prove very convenient. Now, Gentlemen, we are per-
fectly sure that, if we have left nothing septic in the wound, we shall find no
putrefaction when the dressing is changed to-morrow.
[The subsequent progress of this case has illustrated well the remarks made
at the demonstration, with regard to the effects of a free opening, or the contrary,
under antiseptic management. When I saw the patient on the following day,
I learned that he suffered unusual pain in the afternoon after the operation,
which became very severe during the night, and though somewhat less in degree
at the time of my visit, was still very considerable. The temperature had
risen on the previous evening to 102-4° Fahr., and was now ror8*. Such
a state of things would at one time have alarmed me, and would have made
262 DEMONSTRATIONS OF. ANTISEPTIC SURGERY BEFORE
me fear that putrefaction had occurred. This, however, I felt confident could
not have been the case, and another probable explanation suggested itself.
The peculiar bulging above alluded to, situated over one of the pouches of the
synovial capsule beside the ligamentum patellae, had tempted me to make the
opening in that situation; but the bulging part collapsing on escape of the
fluid, the only way in which I could ensure complete introduction of the drainage-
tubes into the joint was by passing their ends under the ligamentum patellae ;
and I thought it not unlikely that they might have been compressed, and their
function so interfered with. Accordingly, on changing the dressing, I found
that the gauze presented a bloody stain, which appeared sufficiently accounted
for by oozing from the surface of the wound, while the joint was fully distended.
And it appeared that the disturbance to which the articulation had been sub-
jected had led to unusually rapid effusion from the synovial surface, and this
being unable to escape, had produced great tension, attended with pain and
fever. JI at once placed him under chloroform, and made a fresh incision at
the outer side of the limb into the pouch above the patella, and introduced a
drainage-tube larger in diameter than the little finger, after pressing out the
clear serous and fibrinous contents of the capsule. This was of course done
with antiseptic precautions, and a dressing like that employed the day before
was applied. The result was that almost immediately after awaking from the
chloroform sleep, he felt himself entirely relieved of his pain; and not only has
that which was induced by the first operation left him, but he has entirely lost
that which had annoyed him for so long a period previously. The temperature
in the evening was found to have fallen to 99° Fahr., and has since remained
normal, and the discharge, which has continued to be merely serous, has so
diminished in quantity, that when I last saw him (August 15) I substituted
a drainage-tube of medium size for the large one, and was able to direct that
an interval of three days should be allowed to pass before the next dressing.
I must add that he has tested the limb, contrary to orders, by getting out of
bed and resting his weight upon it, but without any of the pain which he formerly
experienced on so doing. In all other respects he is in perfect health.
It happens, by a curious coincidence, that another patient requiring the
same operation has since been admitted under my care in the infirmary ; a man
twenty-six years of age, who, six days before admission, observed a painful
swelling in the left knee, without assignable cause, and both pain and swelling
had since steadily increased. The skin, however, was free from redness, and,
subacute as the case was, I hoped that entire rest, with efficient fomentation,
would relieve him. On the contrary, pain continued to increase during the
next five days, while the temperature rose above 100° Fahr. ; and on the 11th
MEMBERS OF THE BRITISH MEDICAL ASSOCIATION 263
inst. I introduced a large-sized drainage-tube into the joint by incision above
the patella, at the outer side of the limb. With the serous fluid that escaped
were mixed considerable portions of lymph, opaque, and in some parts of
yellowish-white colour ; and these portions proved on microscopic examination
to be masses of pus corpuscles; so that it was clear that the case was just
passing into one of that justly dreaded disease under ordinary treatment, sup-
purative synovitis. The result, as in the former case, was immediate and
permanent relief from pain. His temperature next day was normal, and has
remained so. The discharge, purely serous in quality, is quickly diminishing
in quantity, and the patient eats and sleeps as in perfect health. |
The next patient I wish to bring before you is one who came under my care
six weeks ago with an affection of the inner side of the ankle, which he attributed
to a sprain two months previously, after which he had constant pain in the
part, and increasing thickening of the textures. The outer side of the foot
and ankle looked perfectly sound. We put up the limb in a side splint of poro-
plastic material, and used repeated blistering, but without any advantage ;
pain continued to increase, and it was evident that, if left to run its course,
it would end in caries of the tarsus. I therefore, fifteen days ago, made an
antiseptic incision, expecting to open a joint, but hoping that I should not
find pus. To make an opening into an articulation without the presence of
pus would have been, without antiseptic means, an unjustifiable proceeding ;
but here, as I have said, I hoped not to find suppuration, because I knew that,
if the procedure were antiseptically conducted, the opening into the joint would
do no harm whatever, while I should be able in all probability to get great
benefit through relief of tension by free incision ; and if I should find that no
pus had been formed, this would make the case much more hopeful, because it
would show that the disease was not so far advanced as if suppuration had
already occurred. I was gratified, therefore, to find, on cutting into the soft
substance, which gave very much the same sense of fluctuation, before the
incision was made, as if fluid had been present, that there was no pus—nothing
but inflammatory degeneration of the soft parts, the lateral ligament between
the astragalus and the navicular bone being entirely disorganized, so that when
the finger-nail was applied the softened textures gave way with the utmost
readiness, and the joint lay freely open before us, the cartilages happily appearing
to be sound. [ will now change the dressing, so that you may see the appear-
ance of the part. While the bandage is being cut or removed, the patient,
or an assistant, keeps his hand over the site of the wound, to prevent the dressing
from rising em masse, and pumping in septic air. As I raise the folded gauze
(exactly similar to that which I applied in the last case), I take care that the
264 DEMONSTRATIONS OF ANTISEPLIC SURGERY BEFORE
spray passes into the angle between it and the skin. And now, Gentlemen,
I venture to say here is a novelty for such of you as have not practised antiseptic
surgery. There is the blood-clot still lying in the widely gaping wound, pur-
posely kept open by this drainage-tube, which I introduced down to the open
joint when I made the incision fifteen days ago, and which has never yet been
taken out.
I have not seen this wound myself since I made it. J am sometimes accused
of taking a deal of unnecessary pains with my cases, and it is also said that
any good results which I may get are due to my own personal care. If such
were the case, Gentlemen, if I obtained better results than other surgeons by
the more careful use of the same means, that would indeed be something to be
proud of. But itis notso. It is simply that we are working on a new principle.
Mr. Rice, my house surgeon, who was trained first as a dresser and afterwards
as a clerk under me, does these things exactly as I do them myself. If I were
to go away for a week, a fortnight, or a month, as far as the antiseptic element
is concerned, I should feel I had left my patients in perfectly safe hands. In
this particular instance, Mr. Rice has had sole charge of the dressing after the
first day, and here is the result. I am very glad to see, looking at the foot
now for the first time for a fortnight, that the inflammatory thickening has
almost entirely gone. I had of course made inquiry as to the patient’s progress,
and I had learned from his lips that the pain was greatly diminished, as the
immediate result of the incision. I used to have a great horror of opening
into the tarsal articulations in cases of this sort in consequence of the disastrous
results which I have known to occur, through the spreading of suppuration
among them. But if the skin is unbroken, so that the antiseptic system can
be brought fairly into operation, there is no such danger. Here there has not
only been no disturbance whatever from the operation, but we have obtained
the benefit that we anticipated from free incision. The inflammation which
previously existed has almost, if not entirely, disappeared.
And now let me direct your attention again to this remarkable appearance
of the blood-clot lying in the open wound fifteen days old. If we had not used
antiseptic means, that would have been impossible. Some people say, We can
show you good results without antiseptic treatment. Of course, good results
can be got by good surgery without antiseptic treatment ; but I say this is an
instance of something that could not possibly happen without it. When a
blood-clot existed in an open wound under a moist dressing which was not
antiseptic, it was absolutely certain to putrefy and disappear long before the
lapse of fifteen days. Let us now see what change may have taken place in
this clot. I see, when I raise the upper layer of it from the edge of the wound,
SS See ,—(
MEMBERS OF THE BRITISH MEDICAL ASSOCIATION 2605
that there is about an eighth of an inch of cicatricial margin; yet there is no
pus—there is not even any granulation. How the tissue which is thus formed in
an organizing blood-clot differs histologically from that of granulations, I have
not had time to investigate. But that it differs from granulations functionally
is certain, and that in two ways. First, it has not nearly the same tendency to
contract that granulations have; and, secondly, instead of forming pus under the
influence of the very slightest stimulus, as granulations do, this tissue resembles
normal textures in requiring protracted stimulation to induce it to granulate and
suppurate. Now, cicatrization in an open wound without granulation is some-
thing new ; it never happened in the world’s history without antiseptic means.
We may now dispense with the drainage-tube in this case; and having
removed it from the tubular cavity in the coagulum in which it lay, I will cut
out with scissors a piece of the tube of blood-clot. You observe blood oozes
freely from it. What was once blood-clot bleeds when wounded. It has become
organized and vascularized up to the surface.
If there had been a dressing of carbolic gauze applied next the wound, and
changed daily, we should have had a very different appearance. It seems to
be a difficult thing for me to write the English language so as to make my mean-
ing intelligible. I find the opinion still often attributed to me, that carbolic acid
stops suppuration by some sort of specific agency. On the contrary, I have
pointed out, from my earliest experience in the subject, that antiseptic treat-
ment threw remarkable light upon the subject of suppuration, by showing that
an antiseptic itself, while it prevented putrefaction, stimulated to suppuration ;
so that you have what I have termed ‘antiseptic suppuration’,’ if the antiseptic
continues to act upon the tissues for a certain length of time. If we had not
interposed this layer of prepared oiled silk to protect the wound from the
stimulating action of the carbolic acid in the gauze, we should have had a granu-
lating and suppurating sore long ago. The blood-clot itself in its superficial
layers serves as an additional protection to that which lies beneath; but if
the blood-clot, which must be regarded as a kind of tissue, is stimulated by an
antiseptic, its superficial parts are converted in time into granulations which
suppurate. The interposition of the oiled silk ‘ protective’ shields the clot
more or less completely from this stimulating agency, and, provided that you
can allow a considerable period to elapse between the times of changing the
dressing, so as to avoid the frequent washing of the clot with the stimulating
antiseptic lotion, you may often see cicatrization proceed to its completion
without any granulation occurring. In the present case, it is five days since
the dressing was last changed, and it might have been left longer without risk
* See p. 152.
LISTER II T
266 DEMONSTRATIONS OF ANTISEPTIC SURGERY ‘BEFORE
of putrefaction, the serous oozing being so extremely trifling. [The case had been
dressed four times in all during the sixteen days that had passed since the
incision was made, viz. on the day immediately following the operation (which,
as a rule, should always be the case), and afterwards at increasing intervals,
as the serous oozing diminished. But the deepest part of the dressing, con-
sisting of the protective and the small piece of gauze immediately over it, had
been left in place from first to last, to avoid as much as possible the stimulation
of the clot. I may add, in preparing this paper for the press, that the case has
continued to progress well. The patient told me yesterday (August 16),
that the last trace of the jerking pain which he used to feel left him on the
evening of the day of demonstration ; and Mr. Rice informs me, that, on changing
the dressing on the 14th, after an interval of six days, he found cicatrization
almost complete. We may therefore say, without much risk of mistake, that
this foot has been saved from amputation by antiseptic treatment. ]
The next case is one of ununited fracture in the lower part of the femur
of a year’s standing, in a man thirty-six years of age. Twelve days ago, I cut
down on the outer side of the limb, a very long incision being required. Finding
the fragments overlapping about an inch, I removed portions with the gouge
and hammer from the posterior surface of the upper fragment and the opposing
part on the anterior surface of the lower one, so as to leave two fresh osseous
surfaces in apposition. Without antiseptic treatment, this would have been
a very dangerous operation. The risk of pyaemia would have been so great,
that, in common with most surgeons, I should have regarded such interference
as unjustifiable ; but I think we may venture to say that, with antiseptic treat-
ment in its present form, all such risk may be certainly avoided. It is now
twelve days since the operation. For the first few days blood and serum were
effused very copiously, and we had an arrangement by means of which a large
mass of gauze could be applied in considerable extent under the limb. But
the time has come when it might be put up in a more permanent form. This
plaster-of-Paris arrangement was applied yesterday, while the limb was kept
well extended by the pulleys, the patient being under chloroform. I have here
a limited space for the dressing, and therefore use a correspondingly thick mass
of gauze. This you will find often a matter of importance, as in operating for
strangulated hernia, where you have not much space between the wound and
sources of putrefaction in the perineum. And so in the present case, the window
left in the plaster-of-Paris is occupied by a very substantial mass of gauze.
The discharge of the last twenty-four hours has caused, you see, merely a small
brownish stain upon the gauze, the result of a slight amount of serum, tinged
with the colouring matter of the blood. The ends of the wound were stitched
MEMBERS OF THE BRITISH MEDICAL ASSOCIATION 267
up for about three inches at each side; those parts united by first intention,
and are completely healed. The central part of the wound was left open for
the orifices of three large drainage-tubes. And here again we see the persistent
blood-clot. Two days ago, I took out for the first time the drainage-tubes,
and they were, just as in the case you last saw, lying in tubular moulds in the
coagulum. One of them was permanently removed ; the other two were re-
introduced after being considerably shortened by cutting portions off from
the deeper ends. In taking out drainage-tubes you must be particularly careful
to have the spray properly directed. For as the drainage-tube comes out, air
must enter to take its place, and this air will be septic or not as the spray is
or is not over the wound. Here we see the orifices of the two drainage-tubes,
one of which may probably now be dispensed with altogether. As I remove
them, you observe the tubular beds in which they lay. And here, as in the
last case, we have as yet no suppuration whatever from the open wound.
The protective must never extend beyond the gauze ; if it didso, by excluding
the action of the carbolic acid it would allow putrefaction to spread in under it.
I should have liked very much to have shown you one other case, but as
time does not permit this, I shall mention in brief the main points of it. The
case was one of chronic inflammation of the lower part of the tibia, which had
induced great thickening of the bone, attended with severe and constant pain,
in a girl eighteen years of age. There was a small sinus present, but scarcely
any discharge. Introducing the probe, I found it pass deeply into the substance
of the bone. Supposing that there might be some small exfoliation present,
I proceeded to explore the bone, detaching the periosteum from the surface,
and making an excavation with a gouge and hammer. I found a peculiar
state of things pathologically. The chronic inflammation, instead of producing
merely a softened state of the bone, had led to a conversion of the osseous texture
into granulations. We operated by the bloodless method, and found these
granulations almost perfectly white. I proceeded to dig these out, and got
into cavity after cavity. At one time I thought the probe had gone through
the posterior surface of the tibia, but it proved to have passed into another
cavity in the extremely thickened bone. At last I found that the soft material
at the lower part of the excavation moved when the foot was moved ; or, in
other words, I had opened into the ankle-joint. The result of the whole pro-
cedure was a very large and complicated cavity, and it is to the mode in which
this cavity has been filled up that I wish to direct your attention. Now,
I desired that this should be done by means of organizing blood-clot. If this
is done it saves a great deal of time as compared with granulation and healing
from the bottom, and produces a more smooth and level scar. As for a long
fe
268 DEMONSTRATIONS OF ANTISEPTIC SURGERY BEFORE
time past I have done, I systematically placed the protective right across from
one lip of the wound to the other, and then stretched the small piece of moistened
gauze over, so as to keep the protective flat, in order that the blood-clot might
accumulate under the protective, and so fill the wound. But we forgot to
arrange the limb in proper position. It was allowed to lie resting on its posterior
surface, and on changing the dressing next day I found that a large portion
of the blood had drained out of the cavity. The deepest recesses of the excava-
tion in the bone were indeed filled with clot, but a great cavity still remained.
Well, there was an observation made by my colleague Mr. Chiene not long
since that gave me a hint as to how to do in this case. He observed that, having
systematically arranged for the formation of blood-clot in a hollow wound,
a portion of the blood in his case, as in mine, trickled out, and the blood-clot
only partially filled the wound. After the lapse of sixteen days, Mr. Chiene
proceeded to ascertain by scratching with the point of a knife whether the
blood-clot was organized. He found it was, for blood was effused from the
vessels of the tissue into which it had become converted. Dressing was applied
as before; and the remarkable thing is, that this secondary blood-clot, formed
on the top of the first, became also organized like the first, producing living
vascularized tissue level with the surface of the skin. That observation gave
me the hint how to deal with this case; for it showed that if the blood-clot
is insufficient in the first instance, we may supplement it by letting fresh blood
into it at a later period; and if the secondary clot became organized in Mr.
Chiene’s case, though formed so late as sixteen days after the operation, still
more might such an occurrence be expected if the second bleeding took place
at an earlier period. Accordingly, three days after this operation had been
performed, I took a sharp knife and made a few slight incisions in the sides
of the wound. A considerable quantity of blood poured out, and the limb
being kept on its side, to prevent it from escaping, the result is that, twenty-two
days after the operation, and nineteen days after this secondary procedure,
I could show you still a portion of the secondary blood-clot visible, while the
greater part of it has given place to granulations. [It may be added, that the
patient has lost all her pain from the time of the operation, and that here, as in
the case of disease of the foot and in the ununited fracture, there has never
been the faintest inflammatory blush around the open wound. ]
DEMONSTRATION II—PArT I
Gentlemen.—The first patient I wish to show you to-day presents an
illustration of the effects of ligature of an artery in its continuity by means of
? See Lancet, July 10, 1875
MEMBERS OF THE BRITISH MEDICAL ASSOCIATION 269
prepared catgut applied antiseptically. The opportunity of showing him to
you, I owe to my colleague Mr. Annandale, under whose care he has been.
The case was one of aneurysm of the upper part of the femoral artery ;
but as it would not be right for me to anticipate Mr. Annandale in the publication
of its details, I shall merely mention to you the main point that I wish to illustrate.
The external iliac artery was tied under spray, the operation (at which I happened
to be present) being performed with strict regard to antiseptic management,
while the important matter of the use of drainage-tube was not neglected.
The operation was performed on the 23rd of June, and the wound was
absolutely skin-whole in fifteen days, without the occurrence of any suppura-
tion at all.
[Mr. Furneaux Jordan, of Birmingham, was now kind enough to come forward
and examine the patient, verifying the fact that there was no pulsation in the
artery at the groin. Mr. Lister then proceeded. |
The immediate object of the operation has therefore been attained—the
vessel has been permanently obstructed at the part tied ; and this has been done
without the occurrence of any suppuration, and by a mode which, I think we
may venture to say, involves no danger whatever, provided it be properly
carried out. The two great risks of an operation like this are, of course, secondary
haemorrhage, and diffuse suppuration in the cellular tissue around the peritoneum;
and both of these are securely guarded against by proceeding in this manner.
I believe myself that this is a pretty perfect method of obstructing a vessel in
its continuity ; I do not see that we can wish to have it improved upon. I there-
fore regret extremely to find that it is still distrusted in various quarters, even
by those who use catgut for the ligature of arteries in ordinary wounds. They
do not trust it for tying arterial trunks in their continuity. I regret this the
more, because I feel it is to a certain extent my own fault. When I first
published on the subject, I was not aware myself of the proper mode of pre-
paring the catgut. I had prepared it right, but by a mere accident. I described
the mode of preparation in the Lancet,’ as steeping the catgut in a mixture of
carbolic acid and oil. It so happened that the carbolic acid which I used was
liquid carbolic acid, so called—that is to say, crystallized carbolic acid, liquefied
by the addition of water. Now, this water makes all the difference in the world.
When oil is added to this liquid carbolic acid, a considerable portion of the
water is deposited in the form of very fine particles, which are suspended in the
oil; and it is this mixture—this emulsion if we may so call it—of oil and water
which causes the remarkable physical change in the animal tissue of which
catgut is composed, that alone renders it fit for our objects. The tissue of the
* See Lancet, April 3, 1869 (p. 86 of this volume).
270 DEMONSTRATIONS OF ANTISEPTIC SURGERY BEFORE
catgut in the ordinary condition is utterly unfit for surgical purposes; as
slippery, when moistened, as a piece of intestine in the dead-house—when you
tie it in a knot, it slips with the utmost ease. But after it has been steeping in
the emulsion of carbolic acid, water, and oil for a certain length of time, it
undergoes a physical change, which I am quite at a loss to explain. As the
tissue lies steeping in this mixture, the first effect is to moisten it somewhat ;
then, as time passes, after about a week, you find that, instead of becoming
softer, more swollen, and more opaque, as you would expect, it is, on the con-
trary, growing less opaque and beginning to shrink ; and in about three months,
though still softer than dry catgut, it is comparatively firm, and quite trans-
parent. Now, if you take a fresh piece of dry catgut and put it into this same
sample of the preparing liquid, you will find the second piece become in the
first instance partially moistened like the first; a fact which renders it in-
explicable to me, why the former piece should have undergone what looks like
a partial drying. But whatever the explanation, the all-important fact is this,
that after the catgut has been thus partially dried, so to speak, in this moist
liquid, it is now no longer liable to be made slippery by being steeped in water
or the animal juices at the temperature of the body: it is indeed rendered
softer and somewhat opalescent, but a reef-knot tied upon it holds better than
one on waxed silk. I repeat, when I first published on the subject, I was not
aware of this circumstance. I had got the catgut properly prepared, but it
was by mere accident that the water which is essential to the process was present
in the mixture that I used; and, ignorant of its importance, I omitted to
mention it in the description which I gave of the mode of preparation ; whereas
mere steeping of catgut in a solution of dry carbolic acid in oil, though it of
course makes it antiseptic, leaves it perfectly unfit for use as regards its physical
properties. When I found out my mistake, I sought to remedy it by insisting,
in subsequent publications, upon the importance of the presence of the water
in the preparation of the catgut; but I never stated, as I now do, that I had
originally described an untrustworthy method. I very much regret this bad
result of what turns out to have been premature publication ; and I earnestly
hope that this public confession of my mistake will have the effect of preventing
any further bad consequences from it.
The catgut does not spoil by being kept a long time in the preparing fluid
of oil, carbolic acid, and water. Here is some that was put in six years ago
last month. It is now just as good as ever. Thin as it is, I cannot break it
with any reasonable force. If you were going to tie the external iliac, you
would use a thicker piece than this ; partly, in order that it may stand any
strain to which it could be reasonably subjected in the act of ligature, and partly
MEMBERS OF THE BRITISH MEDICAL ASSOCIATION 271
that, a longer time being required for the absorption of the more substantial
material, it may remain longer as a mechanical barrier to the force of the
circulation.
[In this point of view there is another important advantage possessed by
catgut properly prepared, viz. that it is much less rapidly absorbed than that
which has been for a shorter time in the preparing liquid.
I would strongly advise any surgeon, who proposes to ligature an artery
in its continuity with catgut, to test for himself the quality of the article ; since
those who sell it are tempted, if their stock of old catgut has run out, to supply
that which has not been long enough prepared. In order to ascertain if it is
trustworthy, a piece should be steeped for an hour in water about the tempera-
ture of the body, as in a vessel at a suitable distance from the fire. If then
a reef-knot tied upon it does not slip, it is fit for use. And it will be well for
the surgeon to keep a stock of the material for special purposes like these, testing
it in the first instance in the manner described, after which he will be sure that,
being still kept in the preparing liquid, it will be at least equally good at any
subsequent period. If these points are attended to, there will be no further
complaints about untrustworthiness of the catgut.*]
I have now, Gentlemen, to bring before you two cases illustrating a some-
what interesting example of the usefulness of the catgut, namely, for the arrest
of haemorrhage from a wounded vein.
Nineteen days ago I removed this patient’s mamma, and at the same time
cleared out the entire contents of the axilla, thus taking away, along with the
fat, a number of scirrhous lymphatic glands, one of which lay immediately
beneath the clavicle. In performing the operation, you may cut freely enough
on the side towards the chest ; but towards the axillary vessels, the glands,
* When it is requisite that the cord should be able to withstand all the strain to which the human
hands can subject it, as, for example, if it be used for the pedicle in ovariotomy (in which case, I may
remark, the pedicle would have to be well subdivided), the material must be of specially strong quality
to begin with. Catgut consists of the peritoneum, together with muscular fibres, of the small intestine
of the sheep ; and the common kinds are either the entire tube of the gut, or longitudinal strips (accord-
ing to the thickness required) simply twisted, dried, and subjected to sulphurous-acid vapour, or other
chemical agents. But for special purposes, as, for example, the manufacture of fiddle-strings, the cord
is made of several narrow strips twisted together, and is then very much stronger. Such catgut can
be obtained of the musical-instrument makers, but is of course then unprepared in our sense, unfit for
surgical purposes, and must be kept in the preparing liquid for a due length of time. For the sake of
those who wish to prepare catgut for themselves, I may repeat here the proportions which I have found
the best for the purpose. Add one measure of water to ten parts by weight of crystallized carbolic acid,
mix and add one measure of the mixture to five measures of olive-oil, in a suitable jar or wide-mouthed
bottle ; then at once introduce the catgut, the hanks being opened up to allow access of the liquid to
them ; cover, and set aside in a cool place. Some water is gradually precipitated to the bottom of
the vessel, and it is necessary to prevent any part of the gut from coming in contact with this
precipitated water. A simple way of ensuring this is to put in as many marbles as will cover the bottom
of the vessel.
272 DEMONSTRATIONS OF ANTISEPTIC SURGERY BEFORE
with the loose tissue about them, should be detached with the fingers, and any
considerable-sized venous branch tied before it is cut.
[If the incision is carried parallel to the margin of the pectoralis major
to near its insertion into the humerus, and the integument is raised a little
from the edge of the muscle, and also freely dissected backwards to the fold
of the latissimus dorsi, there will generally be obtained satisfactory access for
dealing in this manner with glands situated even at the apex of the axilla; the
pectoralis being drawn well forward, when necessary, by means of a copper
spatula. If, however, the space thus obtained is not sufficient, whether for
the removal of glands in that situation, or for the arrest of haemorrhage there,
the skin should be at once dissected up from the pectoralis, and the muscle
divided transversely from the margin towards the collar-bone to any degree
that may be requisite. When I first adopted, seven years ago, the practice of
systematically clearing out the contents of the axilla, I divided both pectoral
muscles in all cases (the pectoralis major only partially), and though I have
since found that this is not generally necessary, yet the experience of the earlier
cases was valuable, by showing that the division of the muscles, though it appears
a severe procedure, does not seriously complicate the operation, either as regards
its performance or its ultimate results. The arm being kept bound to the side,
the divided muscles unite quickly, and the patient gives, in time, the best
evidence that their functions are not materially impaired by being able ‘ to do
her back hair ’.]
In the present case, one of the glands was so very close to the vein that,
as I was endeavouring with the fingers to detach it, a venous branch broke
at its origin from the axillary, the result being an aperture in the venous trunk
about an eighth of an inch in diameter. I seized the opening in the vein with
catch-forceps, and put a catgut ligature upon it, but the thin slippery tissue of the
venous coat slipped from the grasp of the knot. I madea second similar attempt,
and again the same thing occurred. What was now to be done? Without
antiseptic treatment I should have been a good deal at a loss. To have obstructed
the main vein of the limb by tying it across like an artery, would have been
most undesirable ; and to have introduced a pad of lint into the wound, to
compress the orifice, would have been very unsatisfactory practice.
I did, however, what I had long contemplated doing, if such a circumstance
should arise. All flow of blood being temporarily stopped by pressure on the
vein to the distal side, I threaded a fine sewing-needle with the finest catgut,
and passed it through the coats of the vessel at opposite points of the wound,
and at a short distance from its edges, and then, cutting off the needle so as
to leave two threads in its track, tied one thread round each half of the wound.
—
MEMBERS OF THE BRITISH MEDICAL ASSOCIATION 273
The purchase thus secured upon the venous texture prevented the ligature
from slipping, and the bleeding was permanently arrested. The healing of the
wound has proceeded undisturbed, and cicatrization is, you observe, already
almost complete. Here the small part that remains unhealed being entirely
superficial, it is no longer needful to use the spray in changing the dressing.
Another reason that has made me bring this patient before you is, that
you may see how the drainage of the axilla was provided for, and this I believe
to be a matter of great importance. In all previous cases of this kind, when
it was necessary to clear out the axilla, my practice had been to extend the
transverse incision made for removal of the mamma, and introduce a drainage-
tube at the outer angle of the wound. But if this is done, it will sometimes
happen, if the patient be stout, that in spite of the presence of a substantial
pad of folded gauze between the arm and the chest, the skin of the fat side
and that of the fat arm will come in contact with each other, and the drainage-
tube will become obstructed, leading to tension in the axilla, and, it may be,
inflammatory suppuration. But here, for the first time, I have got over this
difficulty completely, by making a special perforation for the drainage-tube so
far back as to be out of the way of the pressure of the arm. Here, you observe,
is the place where the tube was inserted, viz. in the angle between the arm
(as it lies against the side) and the back. Thus, while you avoid a needlessly
long incision, you have the most complete possible drainage, and the result,
as you see here, has been very rapid healing. We all know that wounds after
removal of the mamma may heal quickly, and sometimes without suppuration,
without any antiseptic treatment at all. But this, I suspect, could not have
been an instance of that kind. A large amount of skin implicated in the disease
had been removed, so that, notwithstanding the use of button-stitches,’ tension
was great; and if we add to this the presence of the large hollow wound in
the axilla, it is not at all likely that under any treatment not antiseptic, healing
would have occurred without suppuration, as it has done here.
The other patient whom I wish you to see, as an illustration of the arrest
of venous haemorrhage by means of catgut, will now be brought in. She had
long suffered from varicose veins, which you see conspicuous in the leg, even
in the recumbent position in which she is ; and I was asked to see her on account
of haemorrhage that had occurred from a tumour about as big as an orange,
which had formed in the ham, the most prominent part being formed of blood-
clot. It was evidently composed of a mass of greatly distended veins, one of
which had given way by ulceration. The case seemed urgently to demand
interference, and I resolved to remove the mass—a thing which I should have
*See Lancet, June 5, 1875 (p. 241 of this volume).
274 DEMONSTRATIONS OF ANTISEPTIC SURGERY
hesitated in doing without antiseptic measures, as I felt sure that I should
open into large varicose veins. Such proved to be the case, as you see from this
preparation of the part removed. On section, the most prominent portion
is shown to be composed of coagulum, while the deeper surface presents numerous
large vessels. They have shrunk a good deal since they were removed, but
when the operation was performed they were almost as thick as my little finger.
And now we have to speak of how the veins, which lay open in the wound, were
dealt with. Some of them presented transverse orifices, but others had been
divided more or less longitudinally. I tried, by detaching the veins from the
surrounding parts, and clipping away some portions, to get the vessels to present
themselves in transverse section, so that I might tie them with catgut in the
ordinary way; and in most instances this was satisfactorily accomplished.
But there was one large vein presenting a longitudinal slit about five-eighths
of an inch in length, so connected that I could not readily deal with it as with
the others. I therefore adopted a practice which will, I believe, prove a valuable
addition to our resources, in wounds of large venous trunks. Using a very fine
sewing-needle and finest catgut as before, I sewed the two lips of the wound
together by continuous or glover’s stitch; leaving the calibre of the vessel
intact. Now, I do not think any man would have been justified in doing that
with ordinary silk or cotton without antiseptic measures. To do so would
have been to run imminent risk of suppurative phlebitis and pyaemia. But by
proceeding antiseptically we incurred, as I believed, no such danger, and the
result is, as you see, so far satisfactory. It is now three days since the wound
was dressed last, and five days after the operation. The discharge of the three
days has caused, you observe, a merely trifling serous stain upon the gauze.
And there is entire absence of any inflammatory disturbance. In performing
the operation, the skin having been very thoroughly washed with 1 to 20 carbolic-
acid lotion, I took care to cut wide of the tumour, so as to keep clear of the
putrefactive material on the exposed clot ; but though a considerable portion
of skin was thus taken away, I was able, by dissecting up the integument a little
at each side, to free it so that its edges could be brought together closely by
suture, except at the spot selected for the insertion of a small drainage-tube.
You see the blood-clot still lying at this spot, while the stitches retain their
places without any suppuration about them. [Healing afterwards proceeded
to its completion, without gaping of the wound or any other untoward circum-
stance. It should be mentioned, that bloodlessness of the operation was pro-
vided for by encircling the thigh with a constricting elastic band, after emptying
the limb of its blood by keeping it elevated for a few minutes in the vertical
position.
AN ADDRESS ON THE TREATMENT OF WOUNDS
Delivered before the Surgical Section of the International Medical Congress, London, August 1881.
{[Lancet, 1881, vol. 11, pp. 863, 901; Transactions of the International Medical Congress,
London, 1881, vol, li, p. 369.)
Mr. PRESIDENT AND GENTLEMEN.—To those of you who know from personal
experience what antiseptic measures can do for surgery it may well seem strange
to find some who have taken part in this discussion still assigning them a secondary
place in the treatment of wounds. The explanation of this fact is, I believe,
to be found chiefly in the success—nay, the brilliant success—sometimes obtained
without the use of any antiseptic means whatever. This has been conspicuously
the case with abdominal surgery, and especially with ovariotomy. Ovariotomy,
indeed, has sometimes been spoken of as a touchstone of the efficacy of the
antiseptic treatment. The success which has attended antiseptic ovariotomy
has been regarded as a signal proof of the truth of the antiseptic principle.
Such, however, has never been my own view. Mr. Spencer Wells and Dr.
Thos. Keith achieved results which astonished the world before strict antiseptic
treatment was thought of: and when, several years ago, Dr. Keith expressed
to me an intention of performing ovariotomy antiseptically, I strongly dissuaded
him from his purpose. I knew his already brilliant success; I felt that our
spray apparatus was as yet inadequate for the production of a cloud sufficiently
large to cover the whole field of operation, and sufficiently fine to avoid needless
irritation ; and I was also aware that such operations are often both very pro-
tracted and very anxious, while in proportion to the duration and the anxiety
of an operation is the chance of the neglect of some apparently trivial yet
important element in the procedure. And if the antiseptic treatment were
attempted in ovariotomy and failed in its immediate object, I felt that it would
be not only nugatory but injurious. It seemed to me that in any case of ovario-
tomy performed without antiseptic measures there was a contest between effusion
from the wounded surfaces and absorption of the effused serum by the uninjured
peritoneum. If absorption kept pace with effusion, there was no time for putre-
factive fermentation to take place in the effused liquid; but if absorption
lagged behind and effusion predominated, the serum accumulated in the abdo-
minal cavity, and, putrefying, gave rise to septicaemia. Now, supposing an
antiseptic like carbolic acid to be employed in the operation, the peritoneal
1 In preparing these remarks for the press, Mr. Lister has expanded the facts and arguments adduced
during the necessarily limited time at his disposal in the discussion.
270 AN ADDRESS ON THE TREATMENT OF WOUNDS
surfaces, as well as those of the wound, would be more or less irritated by it,
and in proportion to this irritation would effusion be increased and absorbing
power enfeebled, till such time as the temporary effect of the carbolic acid had
subsided ; and if, in spite of the antiseptic means, active septic matter had
been introduced, putrefaction and septicaemia would be the natural result.
At the same time, I believed that the day would come when strict antiseptic
treatment would prove valuable in ovariotomy. Especially did I anticipate
that it would permit early operation for small tumours instead of the patient
being kept waiting in anxiety, as used to be the case, till the tumour should
have attained large dimensions. And in point of fact I think, judging from
the records that have come to us from various quarters, and especially from
Germany, that strict antiseptic treatment has rendered very great service to
ovariotomy ; that it has made the surgeon more independent of healthy sur-
roundings, and also has made less essential the excessively minute care during
the operation, and the close attention after it which we have all so much admired
in the practice of Dr. Keith. Thus surgeons generally have been brought, by
the use of antiseptic means, much more nearly towards the high level of Wells
and Keith. Even Keith, on at length adopting strict antiseptic measures with
an improved spray, for a while surpassed himself by an unbroken series of eighty
successful cases. Yet, wonderful as this achievement was, it was only a difference
in degree from his former experience, and assuredly no absolute proof of superi-
ority of the new means employed. Of late I understand he has abandoned the
spray for reasons which I had not the opportunity of hearing him explain when
this subject was discussed at the Congress, and I am informed that he continues
to have admirable results, which cannot surprise us when we remember what
he had arrived at in his early period without adopting antiseptic measures.!
But how, it may naturally be asked, can the success of ovariotomy per-
formed without the use of antiseptic means be reconciled with the truth of the
antiseptic principle ? The answer is, I believe, to be found partly in certain
peculiarities of the abdominal cavity, and partly in circumstances common to
wounds in general. One great peculiarity of operation-wounds within the
abdomen, as compared with those in ordinary situations, is that already referred
to—viz. that the plasma from the cut surface is poured out into a large cavity
lined with a serous membrane disposed to absorb it as fast as it is effused. Thus
without drainage or any outlet whatever for discharge being provided, the
* It is important to bear in mind that Dr. Keith always paid the most scrupulous attention to
cleanliness ; and among the elements of that cleanliness he included what was a very important anti-
septic precaution—namely, the purification of the sponges which he used by boiling them; impure
sponges being undoubtedly a very fertile source of septic contamination, while protracted boiling is
a most effectual means of destroying septic ferments.
AN ADDRESS ON THE TREATMENT OF WOUNDS 277
serum is, under favourable circumstances, prevented from accumulating as it
would in ordinary wounds similarly treated, and opportunity is not afforded
for putrefaction.
Another favourable result of the disposition of the parts is that even if
some accumulation of fluid does take place, the large size of the cavity, naturally
adapted for variations in capacity, prevents the occurrence of tension, which
is so common a cause of disturbance in ordinary wounds. More especially if
a large tumour has been removed, the part affected is left in a state of the
most perfect flaccidity and relaxation.
A further peculiarity in favour of abdominal wounds is due to the high
vital power of the peritoneum. I recollect making a post mortem examination
in a case of strangulated hernia, where death had taken place within forty-
eight hours of the operation, and finding it impossible to discover the site of the
incision by inspection from within the abdomen, so completely had the peritoneal
wound already cicatrized. This high degree of vital energy operates beneficially
in a manner which I shall be better able to explain when I have spoken of some
circumstances common to all wounds in their relations to septic agencies.
At the Cambridge meeting of the British Medical Association last year,
I brought forward facts which showed that the serum of blood is not at all so
favourable a soil for the growth of micro-organisms as I had previously imagined.'
If we take a glass of uncontaminated milk or urine, so arranged that if left
untouched it will remain for any length of time free from organisms, and add
to it a drop of ordinary water, we are sure to find in a few days evidence of bacteric
development in the liquid. Indeed, in the case of milk, which appears to afford
pabulum for almost all varieties of micro-organisms, I have shown that if a
dozen glasses of the liquid in a state of purity, in vessels suitably arranged to
prevent contamination from without, receive each one-hundredth of a minim
of tap water, most of the glasses will develop bacteria, though of different
species in the different vessels, showing how numerous and how various are the
micro-organisms really present in water. Even the comparatively crude liquid
which we call ‘ Pasteur’s solution’, a mere solution of cane-sugar, tartrate of
ammonia, and earthy salts, in which many kinds of bacteria refuse to grow
at all, will be pretty sure to produce such organisms in a few days if a drop of
tap water is added to it. Now from these analogies, and knowing as we do
to our cost that blood serum is but too liable to putrefactive fermentation, I had
+ See vol. 1, pp. 387 et seq.
* See ‘On the Lactic Fermentation’, Transactions of the Pathological Society of London, 1878
(printed in vol. i, p. 353). The results of such an experiment differ according to the season of the year.
In cold wintry weather, when bacteria might be expected to be less numerous, it may happen that but
few of the inoculated glasses show any change at all.
278 AN ADDRESS ON THE TREATMENT OF WOUNDS
assumed that ordinary water contained putrefactive bacteria in a form that
would develop in serum.
But when in the course of an experiment to be again referred to, I drew
blood, with antiseptic precautions, from the jugular vein of an ox into a series
of purified bottles, about half an ounce into each, and, having allowed the blood
to coagulate and the clot to shrink, introduced various quantities of tap water
to mingle with the expressed serum in the several vessels, I found, to my surprise,
that not only an entire minim, but two, four, and even eight minims, failed to
induce putrefaction, although the bottles were kept in a warm box at the
temperature of the body. I have since confirmed this experiment in the ox,
and have also extended it to the blood of other animals—the donkey and the
dog—with similar results. JI even found that putrid blood in full activity, if
largely diluted with water purified by boiling, and introduced in small quantity
in proportion to the serum, failed to occasion putrefaction or the development
of any organisms that I could discover by ordinary microscopic examination.
Yet the same quantities of the same dilutions quickly gave rise to putrefaction
in blood of the same animal altered by mixing it with an equal part of purified
water, showing that they really possessed septic energy, though unable to exert
it upon normal serum. Not that the blood of these animals was in its natural
state incapable of putrefaction, for inoculation with a very small quantity of
undiluted putrid blood soon rendered it highly offensive. But the results of these
experiments seemed to point to the remarkable conclusion that, after having
been widely diffused by means of water, bacteria are incapable of developing in
undiluted healthy serum. In this respect serum is totally different in its be-
haviour from milk, in which, as I have shown elsewhere,! a single Bacterium
lactis, detached from others by a similar process of diffusion by means of water, is
as sure to produce its kind as are a million taken directly from souring milk.
How it is that the diffusion of bacteria renders them incapable of developing
in serum I do not profess to understand. It may perhaps be that when bacteria
are introduced directly from putrid blood, the products of the putrid fermen-
tation adhering to them may induce chemically an alteration in the normal
quality of the serum which, when thus impaired, may prove amenable to the
nutritive energies of the micro-organisms, while conversely copious ablution
with water may remove from the bacteria the associated substances which
thus act as their pioneers. This view might be otherwise expressed by saying
that the bacteria per se are unable to grow in normal serum, and can only
develop in that liquid when it has been vitiated, whether by the addition of
water or by the action of small quantities of the acrid products of putrefaction.
1 Vide Path. Trans., loc. cit. (see vol. 1, p. 373). |
AN ADDRESS ON THE TREATMENT OF WOUNDS 279
—_—
Or, again, it seems to me conceivable that the normal serum may oppose
an insuperable obstacle to the nutritive attractions of an individual bacterium,
but that this may be overcome by the associated action of several of the organ-
isms in close proximity ; after the analogy of the more energetic operation of
a concentrated solution of a chemical reagent. In this case the diffusion by
water would produce its effect by simply detaching and separating the bacteria
from each other. But whatever be the explanation, the fact remains.
I have also made observations on the effects of exposure of uncontaminated
blood to air in different localities, and I have found that even the introduction
of considerable quantities of dust has not led to putrefactive change.
Applying this knowledge to the discussion of ovariotomy performed without
antiseptic precautions, the question naturally suggests itself whether in many
cases any septic organisms have really been introduced into the peritoneal
cavity, either from air or from water, in a condition capable of developing in
the effused serum. And thus we have suggested to us a further explanation
of the success of such operations.
But the facts which have been elicited by the experiments referred to have
a far wider range of application than to the special case of ovariotomy. They
seem to indicate that the putrefaction so apt to occur in wounds not treated
antiseptically is due rather to septic matter in a concentrated form than to
the diffused condition in which it exists either in water or in air. They suggest
the highly important question, Is the spray really necessary ? In other words,
Is there sufficient chance of the air of an operating theatre or private room
containing septic matter which can prove effective in blood serum to make it
needful to regard the question of contamination from the atmosphere at all ?
If the answer must be given in the affirmative, and the choice must lie between
the spray and antiseptic irrigation during the operation at intervals varying
according to the discretion of the surgeon, with syringing of the cavity of the
wound after stitching, and syringing also at every dressing, then I should give
my voice decidedly in favour of the spray, as being more sure of attaining its
object and involving less irritation of the wound, and also (if carbolic acid be
the antiseptic used) much less risk of carbolic poisoning. At the same time
it must be distinctly borne in mind that the spray is, beyond all question, the
least important of our antiseptic means, and that the circumstance that a surgeon
does not happen to have a spray-producer at hand is no excuse whatever for
his abandoning the attempt to obtain aseptic results. But if the apparatus
for the spray is at my disposal, I for my part do not as yet dare to abandon it
By the careful use of our present means, the spray included, we have arrived,
I think I may venture to say, at absolute security of attaining the great object
280 AN ADDRESS ON THE TREATMENT, OF WOUNDS
in view, provided that we have the two essential conditions complied with :
an unbroken skin to start with and the seat of operation sufficiently distant
from any source of putrefaction to admit of adequate overlapping of the sur-
rounding integument by the requisite dressing. I leave it to those who have
done me the honour to visit my wards to judge whether I am guilty of exaggera-
tion in making this strong statement. Such being the case, I should not feel
justified, except on perfectly established grounds, in omitting any part of the
machinery by which results so important to our fellow creatures have been
arrived at.
Nevertheless I am aware that, concomitantly with the perfecting of the
spray, there has been an improvement in other parts of our antiseptic arrange-
ments, and I am not prepared to say that our increased uniformity of good
results may not be due to the latter rather than to the former. And it may
be, for aught I know, that when the International Medical Congress next meets
I shall be able to speak of results of a still higher order obtained without using
the spray at all. For if further investigation should confirm the conclusion to
which our recent facts seem to point, and it should indeed be proved that all
idea of atmospheric contamination of our wounds during operations may be
thrown to the winds, then no one will say with more joy than myself * Fort
mit dem Spray ’.?
The fact that normal serum is not made to putrefy by the addition of
a small quantity of water came out unexpectedly in the course of an experi-
ment designed to illustrate a view which I had long entertained as an inference
from circumstances observed in surgical practice—viz. that an undisturbed
blood-clot has a special power of preventing the development of septic
bacteria. This property I ascribed to the white corpuscles, which are well
known to retain their life long after blood has been shed from the body.?
I supposed these living elements of the clot to produce this effect in accordance
with a principle which I believe I happened to be the first to demonstrate,
but which is now generally admitted—viz. that the tissues of a healthy living
body have a power of counteracting the energies of bacteria in their vicinity
and preventing their development.
The experiment which I related at Cambridge seemed to confirm this view
completely. I have already described one part of that experiment, consisting
of the introduction of small quantities of water into vessels containing uncon-
taminated blood after coagulation had occurred, and the clot had shrunk so as
* This is the title of a recent paper by Professor Bruns, of Tubingen, advocating the substitution
of carbolic irrigation for the spray.
* Last autumn I observed amoeboid movements in white corpuscles from the buffy coat of a donkey’s
blood which had been for two days in a glass vessel.
AN ADDRESS ON THE TREATMENT OF WOUNDS 281
to press out the serum. In the other part of the experiment the water was
introduced before the blood into the purified bottles which were to receive it,
so that any organisms which the water contained were diffused in the entire
mass of the blood before coagulation, and were presumably retained in the clot
when it shrank and pressed out the serum. And unexpectedly great as the
resisting power of the serum to the development of micro-organisms proved to
be, that of the coagulum seemed markedly greater. But our knowledge of the
remarkable influence of the quantity of the ferment in proportion to the serum,
as indicated by the more recent experiments, makes the evidence on which
I relied at the Cambridge meeting far from conclusive,’ so that I cannot now
regard it as demonstrated for blood outside the body that the coagulum has
a greater power than the serum of resisting putrefaction. But what I desire
particularly to mention on the present occasion is an experiment with reference
to the behaviour of the coagulum under the circumstances in which it especially
interests us as surgeons—viz. within the living body. The experiment was of
a character such as it would have been difficult under existing circumstances
to perform in London, so I resorted to the Ecole Vétérinaire of Toulouse, where
everything was most liberally placed at my disposal by my friend Professor
Toussaint and others in authority at the institution.
Having provided four pieces of glass tube, each about an inch and a half
in length and three-hundredths of an inch in diameter, containing two pieces
of silver wire (W) twisted together, with a little piece of
fine linen cloth (L) fixed between them at their central _——, (|
part, the whole apparatus having been purified by
steeping in a strong watery solution of carbolic acid, and subsequent boiling
in water and drying over a lamp, I applied to each bit of linen one-twentieth ot
a minim of septic liquid, which was in the case of one of the tubes undiluted
putrid blood, in the second that blood diluted with ten parts of pure (boiled)
1 If septic liquid is diffused through blood before its coagulation, the bacteria are probably almost
all, if not all, entangled in the meshes of the fibrine, and retained by them when the serum is pressed
out by the shrinking clot. On the other hand, if the liquid of inoculation is added after the contraction
of the coagulum, the bacteria are, in the first instance, confined to the serum. Hence, supposing the
serum and clot alike in their resistance to bacteric development, we should expect, according to our
present knowledge, that different results would follow such a comparative experiment, according as
the serum was large or small in amount in proportion to the clot. Thus, when the serum is relatively
scanty, as is the case with the blood of the ox, which was the subject of the experiment related at Cam-
bridge, if a very dilute septic liquid were blended with the blood before coagulation, the bacteria, few
in proportion to the bulky clot, might fail to develop in it ; but if a corresponding quantity of the same
liquid were dropped in after the clot had contracted, the bacteria, concentrated in the smaller quantity
of serum, might succeed in growing init. Observations of such a character cannot, therefore, be regarded
as affording evidence of any special resisting power on the part of the coagulum as compared with the
serum, unless an estimate is made of the relative amounts of serum and clot in the particular blood
which is the subject of experiment, and a judgement formed accordingly.
LISTER II U
282 AN ADDRESS ON THE TREATMENT OF WOUNDS
water, in the third a dilution with a hundred parts of the water, and in the
fourth a thousandfold dilution. I then exposed the jugular vein of a donkey
in five places, with antiseptic precautions, leaving four intervening portions of
the vessel intact and covered with the integument, and introduced into each
undisturbed portion of vein one of the glass tubes with the septic rag in its
interior, strong ligatures of string purified with carbolic solution being applied
tightly as each tube was introduced, so as to form four venous compartments
or capsules quite distinct from one another, and consisting of vascular tissue
healthy at the outset.
After three days the animal was killed, and the venous compartments
examined. In all four putrefaction had occurred within the glass tube; but
the state of the coagulum outside the tube was extremely interesting. I must
content myself on the present occasion with referring to the condition of the
first compartment, or that which had received the undiluted putrid blood.
Immediately around the glass tube the clot was so much softened by putre-
faction as to be almost diffluent. But next to the greatly thickened wall of
the vein, and forming an adherent lining to it, was a layer of firm coagulum,
in some parts about a quarter of an inch thick, resembling to the naked eye
a perfectly recent clot. Before introducing the tubes into the vein I had drawn
blood from it, with antiseptic precautions, into a number of purified stoppered
bottles containing each the same quantity of septic liquid as the tubes received
(1-zoth minim) of various degrees of dilution, from the unmixed putrid blood
to a mixture with 100,000 parts of boiled water. The bottles received each
about as much blood as a venous compartment contained, and they were kept
at the temperature of the body. Three out of four which had received the
100,000-fold dilution, as well as two kept uninoculated as standards of com-
parison, remained permanently free from putrefaction,! but those inoculated
with larger proportions of the septic material putrefied, and those which received
the undiluted putrid blood were, at the time when the vein was examined, in
a state of utter decomposition, presenting a very striking contrast with the
apparently unchanged layer next the wall of the vein.
But unaltered as this layer appeared to the naked eye, the microscope
showed it to be in reality a very different structure from a recent clot. It
proved to be teeming with cells of new formation, far more numerous than the
white corpuscles of the blood, and differing from them altogether in characters ;
being as a rule larger, and often of great size with pellucid contents, and having
as their nuclei bodies more or less closely resembling pus corpuscles. On the
day after the death of the animal and removal of the vein, I continued the
1 The last observation was made nine days after the commencement of the experiment.
AN ADDRESS ON THE TREATMENT OF WOUNDS 283
examination of the first compartment ; and I was tearing off a part of the firm
coagulum from the lining membrane when I opened into a little cavity in the
clot about a quarter of an inch long and one-eighth of an inch in other dimen-
sions, containing a thick liquid of pearly-white colour, the cavity having a thin
grey lining separated by a layer of dark clot from the wall of the vein, except
at one part. Here it communicated with a small venous branch, whose contents
had been entirely converted into this white liquid for a short distance, beyond
which the branch was obstructed by clot. On microscopic examination I found
this white liquid composed entirely of closely packed corpuscles of new formation
like those above described as infiltrating the clot. Here, however, the new cell
development had taken place at the expense of all the original constituents of
the coagulum, so that the fibrine had entirely disappeared, and only a stray
red corpuscle here and there was to be discovered, and no granular débris was
observed. The liquid was, in fact, neither more nor less than pus, and the
cavity a small abscess. The evidence of endogenous cell development was in
this liquid extremely striking. Many of the corpuscles resembled those of
ordinary pus, though of varying dimensions ; but often bodies exactly similar
to the free pus corpuscles were seen still included as nuclei within large pellucid
cells. In one such cell which I sketched there were four nuclei, three of which
exactly resembled the free pus corpuscles. Thus I had the opportunity of
repeating observations made in the course of very similar experiments carried
on as early as 1864, experiments which, I believe, helped to prepare my mind
for applying to surgical practice the conclusions of Pasteur as to the nature of
putrefaction. Those observations have never yet been published, as I was
compelled to suspend the investigation by the pressure of clinical work in
connexion with the development of the antiseptic system. They proved,
however, in the clearest manner that a blood-clot within a vein is, under
septic influence, liable to a genuine suppuration—that is to say, to a change
which is no mere result of breaking down of fibrine and accumulation of white
corpuscles of the blood, but consists of a growth of living corpuscles multi-
plying by endogenous cell development at the expense of the original consti-
tuents of the coagulum.
As to the source of these newly formed corpuscles, we must suppose them
to have been derived either from the white corpuscles of the blood or from
proliferation of elements of the tissues of the wall of the vein. If we conceive
them to have originated in white corpuscles of the blood, it is nevertheless
quite certain that they were not mere emigrated white corpuscles, but that they
had sprung from them as a new and altered progeny. The actual appearances
presented favoured the view that the new cells had been derived from the
U2
284 AN ADDRESS ON THE TREATMENT OF WOUNDS
tissues. On examining stained sections! of the wall of the vessel and the
adherent coagulum, I found that the corpuscles in the latter were similar in
character to those which thronged the interstices of the tissue of the inner part
of the vascular wall; and among the latter were some that conveyed the idea
of transition from the normal tissue elements. And this view seems confirmed
by the fact that I have never succeeded in obtaining any new growth of corpuscles
in coagulum outside the body, although the blood has been subjected to very
various degrees of septic agency and has been kept in conditions similar to
those within the body as regards temperature and moisture, and, indeed, in
every respect, so far as I can judge, except only the influence of surrounding
living tissues.
There was another circumstance observed in the clot within the vein which
I must not omit to mention. Even the parts next to the lining membrane
though not putrefying, had a distinct faint putrefactive odour. This is readily
explained on physical principles by diffusion of the products of the putrefactive
fermentation which was going on within the tube and in its vicinity. Indeed,
one of the other venous compartments, on being opened, gave exit to a small
amount of fetid gas, the remains of that which had been evolved from the
putrefying part, and which had been only partially taken up by the surrounding
parts; but in the other compartments it had been all so disposed of. This
diffusion of chemically irritating products of putrefaction beyond the limits of
the actual septic process seems to me a matter of much importance; and in
the case of the ass’s jugular it appears to explain, what otherwise might be
difficult to account for, the inflammatory thickening of the coats of the vein,
and also of the surrounding tissues. For the striking contrast presented between
the inflammatory changes in and around the vessel in this animal and the entire
absence of such appearances which I have found both in the horse and in the
calf where I have tied the carotid artery antiseptically, with silk in the one
case and with catgut in the other, seems to imply that the septic matter intro-
duced within the vein of the donkey was the cause of the disturbance in question ;
and the mode of its operation would seem to have been that above indicated.
But to return from this apparent digression. I have to add that, although
twenty-four hours had passed since the vein was taken from the animal, I saw,
in the course of a prolonged investigation of the pus in the little abscess, only
a single bacterium. Also I have to mention the important fact that in the
examination of the previous day, when the vein had been just taken from the
body immediately after death, whereas in the softened part of the clot in the
* I gladly avail myself of this opportunity of publicly thanking M. Laulanier, the Professor of
Anatomy in the Ecole Vétérinaire, for his great kindness in preparing these sections for me.
AN ADDRESS ON THE TREATMENT OF WOUNDS 285
vicinity of the glass tube the red corpuscles were utterly altered, and accom-
panied by abundant bacteria of different kinds, some in active movement, the
piece of firm clot from near the wall of the vein showed the red corpuscles often
exactly like those of freshly drawn blood ;* while, if any bacteria were present,
they did not declare themselves to ordinary microscopic examination.
Thus the experiment affords very striking proof of the power of an undis-
turbed healthy coagulum in the vicinity of living tissues to resist the develop-
ment of putrefactive bacteria, even when present in a highly concentrated form ;
while we have, as I believe, an explanation of this power in the multitude of new
living elements with which the clot was peopled.
Turning now to the application of these pathological facts to ovariotomy, we
find that they seem to complete the explanation of the success which has
attended that operation performed without antiseptic precautions. Among the
points in Dr. Keith’s earlier practice which most excited alike my admiration
and my astonishment was the way in which he diagnosed an accumulation of
fluid in the pouch of the peritoneum termed Douglas’s space, and, drawing
off by puncture per rectum with cannula and trocar a quantity of putrid liquid,
saved his patient from impending death. I greatly admired the skill of this
practice ; but I was astonished at the pathological facts. How was the septic
process limited and prevented from spreading throughout the cavity of the
peritoneum? This seems now to admit of interpretation. In such cases
septic matter must have been introduced during the operation in a form capable
of developing in the blood ; and if we suppose a portion of such effective septic
ferment imprisoned in the interior of a coagulum in the space referred to, this
clot, situated within the living body, may be conceived to oppose an obstacle
to the development of the putrefactive bacteria in its substance, as was the
case in the venous compartment of the ass’s jugular. And here the high vital
energy of the peritoneum would come into play. We have seen how rapidly
a wound in the peritoneum may heal, and this rapid healing is, in other words,
the rapid peopling of the lymph in the wound with vigorous new living elements.
For, whatever view may be taken as to the source of these new corpuscles,
* The only change observed in the red corpuscles of this part of the clot was that in some cases
they had an abnormal purple colour, which I presume was due to products of putrefaction diffused
through the clot from the neighbouring putrefying parts.
* The development of cells of new formation in organizing coagula within the living body, first
ascertained, so far as I am aware, by myself in 1864, has been the subject of various observations
of late years, especially by German pathologists, as, for example, Tillmanns. (Vide Centraiblatt fi
Chirurgie, 1897, No. 46.) That this cell development may, under some circumstances, go on to genuine
suppuration is a fact I believe not hitherto published by any pathologist, though the truth of the
occasional conversion of coagula into pus has always seemed to me sufficiently apparent from the
naked-eye appearances of suppurative phlebitis and the beautiful experiments of Cruveilhier,
286 AN ADDRESS ON THE TREATMENT OF WOUNDS
certain it is that the organization of lymph proceeds more rapidly in proportion
as the wounded tissues are in a more vigorous condition. Thus a wound on
the dorsum of the foot of a feeble old man, though strictly protected from septic
influence, heals very languidly ; while a cut in the lip of a child unites with
ereat rapidity. This, indeed, would seem a further argument in favour of the
tissues being the source of the new corpuscles. But be this as it may, the
lymph on the peritoneum becomes very rapidly thronged with new living
elements, and the same will be the case with a blood-clot, which differs from
recent lymph merely in containing the additional and probably entirely neutral
element of the red corpuscles. But in the meantime, as, in the ass’s jugular,
the tissues of the vessel were irritated, as it would appear, by the acrid products
of putrefaction diffused around the septic parts of the clot, and penetrating
to those which were not really septic, so would the parts of the peritoneum
surrounding the clot in Douglas’s space be excited to adhesive inflammation,
gluing the opposed surfaces together by lymph ; and again this lymph, becoming
rapidly organized through the high vital energy of the peritoneum, would oppose
an effectual barrier to the spreading of bacteric development should it extend
to the surface of the clot. At the same time the irritation caused by the putrid
products, where most intense, would induce copious effusion of plasma and
accumulation of putrid serum. In time this state of things would lead to limited
abscess, such as has been occasionally met with after ovariotomy, the discharge
of the putrid pus having in some instances been followed by the recovery of
the patient.’
But the power of organizing blood-clot or lymph to resist the advancing
development of putrefactive bacteria has, like the behaviour of the serum in
relation to putrefaction, a far wider range of application than to the explanation
of the success of ovariotomy performed without antiseptic treatment. It serves,
for example, as I believe, to explain a fact like the following: In Mr. Syme’s
celebrated case of diffuse aneurysm of the axillary artery, treated by ‘ the old
operation ’, the aneurysmal clots had not only enormously distended the axilla,
but reached backwards so as to raise the scapula, and upwards high above the
* It is conceivable that, even without the intervention of a coagulum, a collection of serum in
Douglas’s space, undergoing gradual putrefaction through the influence of some effective septic particle
introduced at the operation, and being prevented from diffusion through the general peritoneal cavity
in the first instance by a state of perfect repose of the patient, might by its irritation cause such adhesive
inflammation as would prove an effectual barrier against the spreading of bacteric development ; for
the putrescent serum would produce inflammatory disturbance not merely in the parts on which it
acted directly, but also by sympathy (through the nervous system) on parts in the vicinity. The serum
of the plasma effused through this agency would be absorbed by neighbouring healthy parts, leaving the
lymph to glue the peritoneal surfaces together, and, becoming rapidly organized, to operate as a vital
barrier against the advance of putrefaction.
AN ADDRESS ON THE TREATMENT OF WOUNDS 287
clavicle. He entrusted to me the duty of compressing the subclavian artery ;
and, as a preliminary measure, made a small incision penetrating through the
deep cervical fascia, so as to enable my thumb to be thrust through the mass
of clots in that situation, and reach the first rib, on which the vessel lay. He
then laid open the mass in the axilla by a free and rapid incision, and scooped
out with his hands enough of the clots to enable him to gain access to the arterial
trunk, and tie it above and below the place of its communication with the
aneurysmal cavity. Making no attempt to remove the rest of the coagula,
which indeed would have been quite impracticable, he simply brought the
cutaneous margins of the wound together by interrupted sutures, the ends of
the silk ligatures being left hanging out of the wound, in accordance with the
then universal practice ; and as this was before the days of antiseptic manage-
ment, no special treatment of that kind was of course employed, but a dressing
of dry lint for the first few days, and water dressing afterwards. Considering
the well-known danger of diffuse suppuration, which without antiseptic treat-
ment used to attend free incision into a mass of extravasated blood, I was
astonished to see both the puncture above the collar-bone and also the main
wound heal in the kindest manner, without more suppuration from the latter
than must have attended a wound made in healthy tissues as a consequence
of the presence of the ligatures. The fact now ceases to be wonderful if we
take into account the circumstance that the outlying clots had been for
several days among the tissues, and had thus naturally acquired new living
elements which would confer upon them the power of fencing themselves
against advancing putrefaction.
Our principle seems, however, to find its widest application in aiding to
explain the possibility of union by the first intention without the use of any
antiseptic means, nay, in spite of the application of septic ones. For such is,
in truth, the apparently cleanly water dressing. As certainly as we remove
it from a wound after the lapse of twenty-four hours, do we find that the diluted
blood serum which then soaks the lint has a putrid smell, implying that it
contains septic ferments such as would assuredly act effectively upon blood
outside the body. And yet, in the not uncommon case of the occurrence of
primary union under such treatment, putrefaction fails to spread into the
wound ; for if it did so it would inevitably provoke suppuration.
Long before I entertained the idea of the antiseptic principle I often con-
templated with wonder the behaviour of a thin layer of lymph or coagulum
between the surfaces of a healthy wound, as contrasted with that which the
same material would have exhibited, had it been placed in similar conditions
as to temperature and moisture, between two sheets of glass or gutta-percha.
288 AN ADDRESS ON THE TREATMENT OF WOUNDS
The absence of putrefaction in the former case, as compared with its occurrence
in the latter, was plainly due in some way or other to the influence of the living
tissues, between which the putrescible lymph or blood-clot lay. Beyond this,
however, all was mystery. Afterwards, when the power of healthy living
tissues to oppose bacteric development became apparent to me, as exemplified
by the inability of bacteria to grow in the mucus of a healthy urethra," I attri-
buted the absence of putrefaction in the healthy wound to a direct control
on the part of its tissues over the septic bacteria. There is, however, a defect
in this explanation—viz. that, whatever be the nature of the controlling agency
of the tissues on the bacteria in their vicinity, it can hardly be conceived that
it is exerted beyond an extremely limited range ; so that in order that it should
be effective, a more accurate and close apposition of the cut surfaces would
seem necessary. than actual experience shows to be required. And here our
new principle comes to our aid, when we learn that the clot itself, as it becomes
organized, acquires the defensive property which remained to be accounted for.
The thinner the layer of the clot, the more rapidly, caeteris paribus, will
it be densely peopled throughout with the new corpuscles, which confer upon
it this defensive power ; and the process will also advance quickly in proportion
as the tissues of the cut surfaces are vigorous and active. And thus we have
the rationale of the rules of the older surgery in aiming at union by the first
intention—viz. to perform the operation as much as possible by clean cuts
with a sharp knife that shall injure the tissues as little as may be, apply the
cut surfaces closely together, at the same time providing an outlet for effused
blood and serum, and afterwards endeavour to avoid inflammatory disturbance,
which, in proportion to the degree in which it exists, enfeebles the vital powers
of the part affected.
Yet sound as these maxims were in the then existing state of surgical science,
the best efforts of the surgeon were too often thwarted by ‘ unhealthy actions’,
as he termed them, of which he did not understand the cause, and which he
was consequently powerless to prevent. And we must not allow an exceptional
case like ovariotomy to blind our eyes to the truth that the disasters of surgery
in the past have been essentially caused by septic agencies.? Simplification
of our means of procedure is no doubt in itself highly desirable, and I have
already indicated one direction in which it may possibly be attained. But the
safety of our patients incomparably transcends such a consideration, and it
would indeed be a grievous thing if our desire for simplicity should induce us
2 See Transactions of the Royal Society of Edinburgh, vol. xxvii (see vol. i, p. 275).
* Under the term ‘ septic’ I of course include all unhealthy conditions due to the development of
micro-organisms, whether the changes which they occasion in the organic fluids and solids be or be not
accompanied by putrefactive odour.
AN ADDRESS ON THE TREATMENT OF WOUNDS 289
in any degree to relax our efforts to carry out the strict antiseptic principle,
the strenuous endeavour so to deal with wounds as to prevent from first to
last the development in them of pathogenic organisms.1 The means by which
this object may be most surely and at the same time most conveniently attained
will, no doubt, vary greatly in the future in accordance with our ever-advancing
science ; but whatever modifications we may admit in our methods, let us at
all events never be satisfied with any that does not yield results at least as
good as those which it is now in our power to secure.
If we suffer ourselves to be drawn aside from the strict antiseptic principle,
we shall not only subject our patients to the risk of the old disasters, but we
shall be compelled to withhold from them the benefit of valuable procedures
which strict antiseptic management alone can warrant. Take as a single
example the case of a loose cartilage in the knee-joint. To remove it by free
incision is the most simple and satisfactory treatment, except for the attendant
danger which was formerly so great as to be prohibitory, but of which our present
means of carrying out the antiseptic principle have entirely disarmed it. If
such a procedure was ever ventured on without antiseptic means, the only
chance of success lay in accurate closure of the wound with a view to primary
union. On the other hand, under antiseptic management, I systematically
abstain from closing the wound completely, leaving a part unstitched for the
introduction of a drainage-tube, so as to guard against the inflammatory distur-
bance which might otherwise result from accumulation of fluid in the articular
cavity. In other words, I abstain from the only means which would have
afforded hope of success without antiseptic treatment, and I adopt means which,
without antiseptic treatment, must infallibly lead to disaster through septic
suppuration of the articulation. Here, then, I conceive we have a true touch-
stone of the truth of the antiseptic principle. The loose cartilage which I hold
in my hand was removed from the knee of a gentleman a fortnight ago. It lay
imprisoned in the angle between the anterior part of the articular surface of
the tibia and the femur. I extracted it by free incision ; and as the situation
was one which did not admit of convenient insertion of a drainage-tube into
the joint, I left the wound widely gaping throughout. That patient has not
since experienced the slightest uneasiness, nor has there been any disturbance,
local or constitutional.
And this leads me to make the general remark that under strict antiseptic
treatment union by first intention has no longer the importance it used to possess.
As regards the essential points of avoidance of inflammation and fever, of pain
1 The term ‘pathogenic bacteria’ has been introduced by the German pathologists to signify bacteria
which give rise to disease in the animal body by developing within it.
290 AN ADDRESS ON THE TREATMENT OF WOUNDS
and danger, it is a matter of absolute indifference whether primary union occurs
or not. Nay more, as in the case just referred to, if we wish to make doubly
sure of preventing all inflammatory disturbance, it is sometimes well to avoid
stitching, and the tension which may become associated with it. There is at
present in King’s College Hospital a man on whom I operated three weeks
ago for ununited fracture of the humerus, cutting down on the fragments and
uniting them by a suture of thick silver wire after sawing off their extremities.
Now, in a case of this kind some years ago in which I applied stitches to the
wound, although a good-sized drainage-tube was used, a certain amount of
inflammatory disturbance occurred, which I could only attribute to want of
-ufficient exit for the abundant sanguineous oozing that took place from the
osseous surfaces. This disturbance led not merely to some deep-seated suppura-
tion, but to necrosis of a portion of one of the fragments, which greatly retarded
the cure. Hence I have since abstained from anything like close stitching
after such operations, and in the patient referred to the wound was left gaping
widely. At the next dressing it was found occupied by blood-clot, which has
subsequently become organized, and at the same time has contracted so much
that the cicatrix, already nearly complete, promises to be little more than linear.
Meanwhile there has been no uneasiness, redness, or swelling, and no febrile
disturbance, and if any imperfect pus whatever has been formed, it has been
only from the surface of the organized coagulum as a result of slight unavoidable
stimulation by the antiseptic used in the dressing. And here we have, as
I believe, another touchstone of the antiseptic principle, showing that it is true,
and gives results both new and important. For without effective antiseptic
means of some kind or other such a course of such a wound would, I believe,
be impossible. The impermeable protective layer applied next the wound
under the antiseptic gauze prevented evaporation, and maintained a constant
state of moisture of the surface of the clot. Now, a moist dressing other than
an antiseptic one could not have failed to occasion putrefaction of the exposed
coagulum and suppuration of the cavity of the wound.t Yet, all who are
* In an animal like the donkey the reparative energies of the tissues would appear to be greater
than in man, as is indicated by the well-known facility with which healing by scabbing is obtained in
veterinary practice. Yet, in the donkey’s jugular, it was only the parts of the coagulum near the wall
of the vein that had escaped putrefaction. Even in such an animal, therefore, an exposed clot covered
with water dressing would putrefy, with the exception of the parts next the tissues ; and these would
granulate and suppurate. Under a dry dressing, indeed, even in man, healing without suppuration
has been sometimes seen in open wounds of considerable extent, especially when the affected part has
been kept completely at rest and supported by methodical compression, as insisted upon by M. Alphonse
Guérin and Mr. Gamgee. Here the dry dressing appears to have an antiseptic influence by causing
an inspissated state of the serum in the dressing, for it has been shown by Naegele that bacteria are
unable to develop in concentrated organic solutions. Such results of mere dry dressing cannot, however
be reckoned on with anything like certainty.
AN ADDRESS ON THE TREATMENT OF WOUNDS 291
familiar with antiseptic practice know that it is a common thing to see the
organization of the blood-clot proceed under the protection of the superficial
layer of coagulum to complete healing without a particle of suppuration, a scar
being found when the superficial layer is detached.
Time would not permit me to refer to all that has been communicated
by those who have taken part in this discussion. I cannot, however, forbear
making a passing allusion to the extremely remarkable results which have been
related by Professor Esmarch as obtained by his permanent dressing—results
so surprising that they would be incredible were it not for the perfect trust-
worthiness of the authority that vouches for them. And I would ask those
who advocate mere cleanliness, as distinguished from antiseptic practice, how
they can reconcile their views with facts such as these? What can be more
dirty, in the ordinary acceptation of the term, than a wound left covered up
with the same dressing for weeks together, the original blood and serum remain-
ing upon it intact under this ‘ Dauer-Verband’? Yet it is surgically clean
because it is aseptic. On the other hand, the aesthetically cleanly water
dressing is surgically dirty, because it contains elements which give rise to
septic changes in wounds.
One other point which has been referred to in connexion with this debate
is of so much importance that I cannot but notice it. The old objection has
been revived that antiseptic treatment leads the surgeon to concentrate his
attention upon local measures, to the neglect of general hygienic arrangements
and a due consideration for the constitutional state of the patient before subject-
ing him to operation. I do not think that this charge is at all warranted by
facts. For my own part, I have from the first used antiseptic treatment even
for superficial wounds and sores, not so much for the sake of the individual
cases (which I knew did well, as a rule, under water dressing) as for the express
purpose of preventing them from contributing elements of general unhealthiness
to the hospital ward. And if I have sometimes allowed the beds under my
charge to be more crowded than is in accordance with the views of modern
hygiene, it has been only after such a condition, originally brought about by
accidental circumstances, had proved as a matter of fact consistent with perfect
healthiness of the patients. The septic element being suppressed, less space
was found to be essential to salubrity.
As to the other part of the charge—viz. that antiseptic treatment leads
to a less careful selection of patients for operation than ought to be made, it
seems to me to be refuted by the success which confessedly attends the practice.
If, indeed, the charge were well founded, and we did really operate upon patients
whose constitutions rendered them unfit subjects for such interference, good
292 AN ADDRESS ON THE TREATMENT ‘OP WOUNDS
general results obtained under circumstances so highly unfavourable would
afford the most conclusive proof of the value of the local treatment employed.
But the truth is, that the suppression of the septic element enlarges the capa-
bilities of surgery in the constitutional direction no less than in the local; and
enables us to extend the benefits of needed operations to patients whose con-
stitutions are so enfeebled by age or vitiated by disease that without strict
antiseptic treatment no prudent surgeon would venture to meddle with them.
I appeal to the logical faculty of this great assembly of eminent men, and
beg them to consider carefully in relation to this question the familiar case
of a simple fracture or dislocation. Do we feel anxiety regarding the state of
the constitution of a patient who has received such an injury ? The mischief
done is in itself of a worse character than the surgeon ever inflicts. Yet so
long as the unbroken skin shields the bruised and lacerated tissues from the
access of materials coming from the external world, repair advances safely,
no matter what be the constitutional condition ; the exceptions being so
extremely rare that we practically leave them out of consideration altogether.
It therefore surely follows that if we could contrive a treatment of our wounds
which would have all the advantages of the unbroken integument, we might
operate without anxiety on account of the constitution.
To provide a condition of our operation-wounds that shall put them fully
on a par with subcutaneous injuries is plainly the ideal of our art. Towards
the attainment of this ideal we have already made large progress ; and towards
its full achievement, so far as it be possible, I would earnestly invite the best
efforts of my hearers.
AN ADDRESS ON CORROSIVE SUBLIMATE AS
A SURGICAL DRESSING
Delivered at the Opening Meeting of the Medical Society of London, October 20, 1884.
[British Medical Journal, 1884, vol. ii, p. 803.]
Mr. PRESIDENT AND GENTLEMEN.—When, in an address delivered at the
opening meeting of last session,’ I expressed myself in what some of my hearers
regarded as terms of overweening confidence in the trustworthiness of antiseptic
treatment, I little thought that, a year later, I should have to tell you of failures
on my own part; yet such is the case. Several instances have occurred, within
the last few weeks, of results deviating from our typical experience in antiseptic
treatment, such as I was in no way prepared to meet with, and, in one case,
a fatal event ensued. A lady, on whom I operated for scirrhus of the mamma,
with removal of the axillary glands, died of a spurious pyaemia, or a variety
of septicaemia, an occurrence such as I have not met with for many years past.
We dressed the wound in the usual way. Two days after the operation, there
was pus already present at the anterior part of the incision. There happened
to have been an unusual flow of blood at this part, where we do not, as a rule,
expect much. It is a very unusual thing for pus to appear so early. We used
to say, in what I may term the pre-antiseptic days, that, if we operated upon
sound tissues, suppuration occurred, provided primary union did not take
place, in from three to four days, three days in children, four days in adults,
and, perhaps, in warm weather, rather earlier than four days. For pus to
occur to the amount of several drachms at the end of two days was, therefore,
very unusual, and some special form of organism, I have no doubt, was present.
Micrococci were, indeed, found after death in abscesses which had formed within
the pleura. Nevertheless, though I believe some unusual organism was present,
we have been accustomed to consider ourselves free from the apprehension
of such ill effects ; and though, I am thankful to say, no other fatal case occurred,
there have been several instances of deviation from the typical course, where,
instead of union without suppuration at all, we have had healing retarded by
the formation of more or less pus, undoubtedly of a septic character, in the
sense in which we now use the term septic, that is to say, dependent upon the
development of micro-organisms, although no smell was perceptible. Now,
sir, I need hardly say that one such result as that to which I have referred,
* See p. 453 of this volume.
294 AN ADDRESS ON CORROSIVE SUBLIMATE
a fatal event under circumstances which we had been accustomed to consider
absolutely free from danger, made me reflect most seriously ; and the other
cases, though less disastrous, were also grave cause for reflection.
In looking for the source of our misfortunes, it was to the external dressing
that we naturally turned our attention. The experiences of Mr. Cheyne and
Professor Ogston indicate pretty distinctly that the means which we ordinarily
use are sufficient for the purpose of rendering our wounds free from mischievous
micro-organisms at the time we put on our dressings. Both Mr. Cheyne and
Professor Ogston have found, by using the most advanced methods of investi-
gation, that if a carbolic-acid gauze dressing is changed daily, no organisms are
met with in the discharges. That, I say, seems pretty conclusive evidence
that the means which we have adopted hitherto for the purpose of keeping
our wounds pure, up to the time when the dressings are applied, are sufficient.
With regard to our external dressings, our suspicions tended to turn upon the
eucalyptus gauze. Eucalyptus oil is undoubtedly a powerful antiseptic, and
I have been using it in the form of gauze for a considerable time past. One
difficulty with it is its great volatility. In the first instance I employed gum
dammar, instead of common resin, in the manufacture of the gauze, because
I found that gum dammar held the eucalyptus oil more securely than the resin
does ; but gum dammar is an expensive gum, and, after some trials with common
resin, I thought I was justified in substituting the cheaper material, and for a while
we seemed to get good results with this arrangement. But, as I have already
said, more recently the results were not satisfactory. I mean that, now and
again, a case occurred which was unsatisfactory. On making inquiry of the
manufacturer of our eucalyptus gauze, I found that he had deviated from the
instructions which he had received as to the manufacture; that he often left
the gauze, for a considerable time after it had been charged, exposed in the
air before folding it up, thus affording opportunity for the escape of the volatile
constituent in large amount ; and in hot weather, such as that during our recent
summer, this was more especially apt to occur. We found, as a matter of fact,
that the eucalyptus gauze supplied to us had not the softness which it ought
to have, caused by the adequate amount of eucalyptus oil. I was thus led to
attribute our disasters to imperfection in the manufacture of the eucalyptus
gauze.
These circumstances led to a reconsideration of the subject, and to an appre-
ciation afresh of the disadvantages of any volatile antiseptic substance. Volatile
antiseptics have their own advantages, to which I need not refer, but they have
great disadvantages. In the first place, we are at the mercy of our manufacturer.
The resin and paraffin so glue the folds of the gauze together, if it is allowed to
AS A SURGICAL DRESSING 295
cool in mass, that it must be opened up while warm, and upon the way in which
this is done by the manufacturer much depends as to the quantity of the anti-
septic present in the gauze. In the next place, a volatile antiseptic, such as
either carbolic acid or eucalyptus, has the disadvantage that it requires careful
treatment by the surgeon himself. The material containing it must be kept
in well-closed metallic vessels ; otherwise evaporation soon impairs its qualities.
And in the third place, there is this disadvantage attending all volatile anti-
septics, that the longer the dressing is kept upon the body the less efficacious
does it become ; and who is to say when the time arrives when it has become
so inefficacious that it is necessary to remove it? I have been accustomed to
regard a week as the limit of the time during which a carbolic-acid gauze dressing
may be regarded as effectual; but, beyond the fact that with this period our
results were on the whole satisfactory, we had not what we may call precise
grounds to go upon. In that respect, a volatile antiseptic must always be at
a disadvantage, as compared with a non-volatile one, which will be just as
efficacious at the end of a month, or six weeks, as it is when first applied, provided
it is not soaked with the discharge.
Salicylic acid is a non-volatile antiseptic ; but salicylic acid, as I ascer-
tained from experiments, several years ago, is very far from being as powerful
in antiseptic qualities as carbolic acid, and therefore I have never ventured to
use it for serious cases. JIodoform, while volatile, is very slowly volatile, and,
at the same time, so little soluble in the discharges, that in these points of view
it seems an admirable antiseptic ; but 1odoform is by no means a potent agent
in its action on micro-organisms. I ascertained, some years ago, for example,
that, taking a Io per cent. 1odoform wool, the strongest used, and soaking this
with milk, the lactic fermentation was only a short time retarded, and in the
course of a few days not only the Bacterium lactis, but multitudes of other
kinds of bacteria were seen, in abundance, in the milk. Again, uncontaminated
urine being made to soak such a piece of wool, and then inoculated with putrefy-
ing urine, I found that the ammoniacal fermentation was only a short time
retarded by the iodoform. Hence I was not surprised to learn that, in the
practice of Schede of Hamburg, and others, it had been found that erysipelas
occurred under the iodoform dressings. It is remarkable that iodoform has
such an effect as it has in preventing putrefaction, but it is by no means
a powerful germicide.
But there is another non-volatile antiseptic, corrosive sublimate, to which
attention has been more especially directed of late years by Dr. Koch; and
here I may be permitted to give my tribute of praise to the admirably conceived
and conclusive experiments which he has performed upon this subject. Koch
290 AN ADDRESS ON CORROSIVE SUBLIMATE
proceeds in this sort of way+; he dips a very small piece of silk thread into
a fluid containing the spores of the Bacillus anthracis, known to be highly resist-
ing to the various agencies inimical to low organisms. After this silk thread
has become dry, he dips it in the antiseptic solution to be tested, keeping it
there for a minute, half a minute, five minutes, or any length of time that is
required. He then, by means of water or alcohol, or some fluid known not to
influence the vitality of the spores, washes away the antiseptic from the thread,
and brings into play his beautiful method of solid culture-material. He places
the little bit of silk thread upon a piece of gelatine properly provided with
nutritious material, and of course scrupulously pure, and observes, by means of
the microscope, whether the spores in the silk thread develop or not. He
ascertained, by experiments of this character, that a solution of only one part
of corrosive sublimate in 20,000 parts of water was amply adequate absolutely
to destroy the vitality of the spores of the Bacillus anthracis, about the most
resisting spores that are known. But he found also that as weak a solution
of the sublimate as one to 300,000 parts of a solution of extract of meat was
sufficient to prevent the development of the spores so long as they remained
in it; but when the silk thread, having been for any length of time in this
exceedingly weak solution, was withdrawn from it, washed, and then placed
upon the nutritious gelatine, development occurred as if the spores had not
been exposed at all to any injurious agency; and thus Koch established in
a most definite manner the distinction, and a very important one it is, between
two different effects of antiseptic agents—one, the action by which the vitality
of organisms is destroyed ; and the other, that by which development is simply
arrested, or prevented temporarily from occurring, without the vitality of the
spores being interfered with. The former we may term ‘ germicidal action’.
For the latter, it is somewhat difficult to find a good English term. I happened,
I believe, to be the first to use the word ‘ inhibitory’ in English physiology, by
the advice of my old friend Dr. Sharpey, with reference to an early paper I was
about to publish on what the Germans term the ‘ Hemmungs-Nervensystem ’ ? ;
and as this same word Hemmung is used by the Germans for this checking or
suspending action of antiseptics, without destruction of vitality, and as it is
very important that we should have some term which distinguishes the one
action from the other, I may venture to employ this same word ‘ inhibitory ’—
a good old English word—for this action of antiseptics, and to speak of their
‘inhibitory action’ as distinguished from their ‘ germicidal action ’.
Now, these properties of corrosive sublimate were such as no other antiseptic
* Vide ‘ Desinfection’. Von Dr. Robert Koch. Mitthetlungen des Kaiserlichen Gesundhetts-Amtes,
1. Band, 1881. SaSeenvOl tp. 67.
AS A SURGICAL DRESSING 297
agent had ever been ascertained to possess in anything like such dilute solutions.
With regard to our purposes in antiseptic surgery, the inhibitory action of the
antiseptic would be sufficient, provided we be satisfied that our wound is left
free from injurious organisms, and that the dressing which we apply itself
contains no such organisms still alive. Then, all we require is that the dressing
should be able to prevent the development of organisms from without into the
discharges with which the dressing may be soaked. That is obvious.
Corrosive sublimate has been used extensively already by our German
brethren, chiefly in the form of sublimate wood-wool, as it is called, in which
one-half per cent. of corrosive sublimate, with an equal part of glycerine, is
mixed with what is termed ‘ wood-wool’, namely, pine-wood reduced almost
to a state of powder by suitable machinery. This is highly absorbent. It is
employed in large masses, and, so used, has given many excellent results. At
the same time, it is somewhat unwieldy in its application. Under certain
circumstances, it is not convenient to have so large a mass as is essential for
its safety, and we have also varying reports as to its efficacy ; and I may remark
that we find some surgeons satisfied with what others would regard as a very
mediocre kind of success with antiseptic treatment.
The circumstances to which I referred at the beginning of my address
naturally made me turn my attention to corrosive sublimate ; and I was desirous,
if possible, to use it in a more concentrated form, so that it might be employed
in a less bulky fashion. Accordingly, I prepared a gauze containing, instead
of one-half per cent., one per cent. of the sublimate.
The first case in which I used it was that of an elderly lady, from whom
I removed the mamma and cleared out the axillary glands. I put immediately
over the wound a piece of prepared oiled silk, which I dipped in a 1 to 500 solution
of corrosive sublimate ; then, over this, sublimate gauze, and outside all an
abundant eucalyptus dressing. On the following day, when we changed the
dressing, I found that, under the oiled silk, exactly corresponding to its extent,
the skin was highly irritated, and was covered with small vesicles. I also found
that the inner side of the arm, where there was no wound, was in the same
state of intense irritation. I covered the irritated parts of the inner side of the
arm with eucalyptus gauze, dipped in a weak solution of carbolic acid, and
I applied to the wound the 1 per cent. sublimate gauze without any intervening
protective oiled silk. On the following day, I found that the little vesicular
pustules, which had formed the first day under the protective, had healed, and
that the inner side of the arm also had recovered from its irritation. How were
these facts to be explained ? I believe the explanation to be this. The 1 to 500
watery solution of corrosive sublimate, prevented by the oiled silk from escaping,
LISTER II xX
298 AN ADDRESS ON CORROSIVE SUBLIMATE
had acted as a powerful irritant upon the skin; but when the 1 per cent. gauze
was applied directly to the wound, the oozing of albuminous discharge from
the pustules and from the edges of the wound mitigated the action of the corrosive
sublimate, and so prevented further irritation there. Again, in the case of the
arm, what had occurred was, free perspiration had taken place, and the per-
spiration forming, with the corrosive sublimate in the gauze, a watery solution,
had produced irritation where the perspiration was, on the same principle as
the watery solution had caused irritation under the protective.
I continued to use a corrosive sublimate dressing in this case. Itso happened
that there was a very free haemorrhage after the operation. I never before
saw small vessels so atheromatous. We had to tie multitudes of little rigid
arteries, and, in spite of this, a considerable effusion of blood took place, and
bagged under the skin. She left town with the outer angle of the wound still
unhealed, and having the remains of the blood-clot exposed in it—the dressing
employed being a piece of absorbent cotton-wool charged with about five per cent.
of sublimate, secured in its place with collodion—and she came every few days
to London to have the dressing changed. On these occasions I found that,
although the serous discharge had soaked the wool more or less, there was no
irritation caused by it; and the blood-clot, in course of time, presented an
appearance which I never happen to have seen before. From the epidermic
edges of the little wound, the epidermis crept over the surface of the blood-clot
like the white claws of an animal, extending over the dark coagulum. We are
familiar with the organization of the coagulum in exposed wounds, and we are
also familiar with the fact that in the course of time the superficial clot may be
removed, and a scar found under it, without any suppuration having taken
place, or any granulation, strictly speaking; but I never happened to have
seen before this formation of epidermis extending over the surface of an exposed
coagulum ; and the explanation I believe to be that, while the sublimate wool
rendered the wound, for surgical purposes, perfectly aseptic, the albuminous
discharge from the wound prevented the sublimate from coming into operation
as an irritant, and so we had, ina peculiarly perfect manner, complied with the
essential conditions for the treatment of superficial sores—namely, the exclusion
on the one hand of septic agency, and on the other of the irritating property
of our dressing. I may add that the wound healed without a particle of pus
having been formed from first to last.
While this case showed that in the sublimate we had an agent that might
give very beautiful results, it also indicated that we were dealing with an edged
tool, which, while it might do admirable work, was very apt also to cut our
fingers ; and the question suggested itself, Was it, after all, possible to use
—_
AS A SURGICAL DRESSING 299
corrosive sublimate in such a way as to get the advantages without the dis-
advantages ? The question, for instance, suggested itself, Suppose the discharge
had been more considerable in this case, so as to soak thoroughly through
and through the dressings, what might then have been the result ? What is
the action of the albumen of serum or blood upon corrosive sublimate ? How
do they act upon each other? It is, I believe, a very general view in the
profession, not to say among professed chemists, that albumen forms, with
corrosive sublimate, an insoluble, or very sparingly soluble, albuminate; and
that this albuminate is inert ; whence the efficacy of white of egg as an antidote
in corrosive sublimate poisoning. In the fourth edition of Miller’s Chemistry,
it is distinctly stated that an albuminate of mercury is formed as a precipitate
when a solution of albumen is treated with corrosive sublimate. In the third
appendix to Watts’s Dictionary of Chemistry, the albuminates are still spoken
of, and, in the intermediate appendices, there is nothing said to modify the
view expressed in the original work, viz. ‘ Mercuric albuminate is a white sub-
stance obtained by precipitating corrosive sublimate with albuminate of sodium
(white of egg)’. If it were really true that the albumen acting in a certain
proportion on the corrosive sublimate would form with it an absolutely inactive
compound, this would be a very serious consideration for the use of corrosive
sublimate in surgical practice. The albuminous (proteid) constituents of the
blood are enormously abundant ; while the quantity of corrosive sublimate we
can use in our dressings cannot be very great. According to the most recent
views regarding albumen, its chemical equivalent is about six times that of
corrosive sublimate; but the quantity of albuminous material in the serum
of the blood is very much more than this in proportion to the sublimate we
could think of employing. My first experiment upon this matter was as follows :
I made a solution of albumen from white of egg, and then introduced it into
some sublimate-wool, the quantity of albumen used being double that which
would be requisite to neutralize the corrosive sublimate, according to the view
to which I have referred. After leaving the albuminous fluid in the wool for
a certain time, I squeezed the wool, and obtained a clear fluid, and I was sur-
prised to find that this clear fluid tasted strongly of corrosive sublimate—an
albuminous fluid, containing twice the quantity of albumen that was essential,
according to the views to which I have referred, for neutralizing the corrosive
sublimate, had picked up from the wool corrosive sublimate enough to give the
fluid that came out a strong taste of that substance. I mixed this liquid with
an equal part of milk obtained from a dairy, and the milk remained perfectly
free from souring, showing that the albuminous fluid which had come through
the wool had antiseptic qualities, as well as the taste of corrosive sublimate.
ne
300 AN ADDRESS ON CORROSIVE SUBLIMATE
I afterwards made other experiments with blood itself, and that to which
IT will now refer was with the serum of horse’s blood. My first attempt to
obtain serum from horse’s blood failed. I wished to get the blood in an aseptic
state, so far as one conveniently could without going too much into detail ;
and I used a glass jar which I had had by me for a long time past, and which
had been used for experiments with regard to catgut, and had certain impurities
adhering to it which could not be cleaned off. I purified this with a 1 to 500
solution of corrosive sublimate, and then introduced into a horse’s jugular
vein a glass tube purified in the same way, and through this tube drew blood
into the jar, and allowed it to coagulate, intending to use the serum which should
ooze out of the clot as it contracted. I was baffled, however, by finding myself
again in presence of a fact which I described some years ago, where antiseptic
precautions had been used in obtaining blood; the clot never contracted.
When I first witnessed this fact, having found the novel procedure of anti-
septic precautions, in taking blood, followed by the novel phenomenon of failure
of the clot to contract, I was disposed to attribute the one to the other, and to
imagine that the destruction of the septic organisms was, In some way or other,
the cause of the absence of the shrinking. Then it was suggested to me that
Liebig had shown, in his Letters on Chemistry, that, if glasses are heated, they
lose, for a time, their usual property of causing certain phenomena of crystalliza-
tion ; and, as my glasses had been always purified by heat, there might be some
peculiar physical property in the glass to account for the circumstance. But
here we find the same phenomenon cropping up, although the glass had not
been purified by heat, and although it had not even a clean smooth surface.
It may be interesting to you to observe that, though the antiseptic pre-
cautions used were but of a rough kind, still no genuine putrefaction has occurred,
in spite of the hot weather, in this blood taken on the gth of September. But
the remarkable fact to which I wish to direct your attention is that, while the
buffy coat peculiar to horse’s blood can still be recognised, it has entirely failed
to contract, and is to be seen adhering to the surface of the vessel. I must
confess it seems to me barely conceivable that the development of organisms
can be the cause of the contraction of the clot under ordinary circumstances,
considering how soon that contraction begins to come into play. Yet to what
else are we to attribute it? It is to me, I confess, a perfect mystery. At the
same time, to us surgeons it must be admitted to be highly interesting, because
in antiseptic surgery, at all events, this is the very condition of things in which
we find the clot. We do not find a clot shrink away, or tend to do so, from the
sides of the wound, but it retains its original bulk until it is gradually diminished
by absorption and organization ; and if a clot forms in the vicinity of a ligature
AS A SURGICAL DRESSING 301
J
upon a large artery, it seems very important that it should not shrink away
from the sides of the vessel, but remain there, in its original dimensions, to serve
its purpose of a plug.
On the same occasion on which I obtained this blood, I received a portion
into another vessel, and stirred it during coagulation to remove the fibrine.
This whipped blood answered my purpose perfectly, because, by virtue of the
remarkable tendency that the red corpuscles of the horse’s blood have to aggregate
into dense masses, and so fall rapidly in the course of a short time, the mixture
of serum and red corpuscles was found, in three hours, to consist of about one-
half corpuscles and one-half serum, and therefore I could use the serum for
the purpose of my experiment.
The experiment was performed in the following manner. A glass tube,
such as this (three-quarters of an inch in calibre and three inches in length),
open at each end, was packed with a certain weight of antiseptic dressing to be
tested, say sublimate-wool, occupying about two inches of the tube; then
a weighed quantity of serum, just enough to soak the wool, was poured in at
one end of the tube held vertically ; it was then left for about half-an-hour
in a warm box at the temperature of the body, after being put into a stoppered
bottle, to prevent evaporation ; then the serum and the sublimate in the dressing
having been allowed to act upon each other for about half an hour, a little more
serum was poured in, the tube being in the same position as before. The result
was that a certain quantity flowed out below, and was received into a test-tube.
The lower part of the wool and the serum in the test-tube were next inoculated
with putrid blood, diluted with ten parts of water, to prevent the smell being
so great as to make one think that putrefaction existed when none had occurred,
a tenth of a minim being applied by means of a suitable apparatus. Lastly,
the wool-tube in its stoppered bottle, and the test-tube with a cap of thin
macintosh tied over its mouth, were replaced in the warm box. The object
of this was to ascertain whether the dressing, after having been thoroughly
soaked through and through with serum, would resist a potent septic inoculation ;
and also whether the fluid that had come through the dressing was itself an
antiseptic fluid. If such should prove to be the case, we should have all the
requisites we could desire for an antiseptic dressing. It was a very severe test,
for it is comparatively rarely that we have such intensely putrefying substances
applied to the surface of our surgical dressings, and it is also comparatively
rarely that the dressings are soaked so very thoroughly with blood or serum.
I used three kinds of sublimate-wool, one containing I per cent.—twice
as much as there is in the wood-wool—one 5 per cent., and the other Io per cent.
I have mentioned that it was on the 9th of September that this was done, and
302 AN ADDRESS-ON ‘CORKOSIVE SUBLIMATE
all these three wools remain perfectly pure, so far as the sense of smell can
detect, to the present time. The bottles are before you, and even in that con-
taining the 1 per cent. wool, you will find nothing but a smell, something between
that of mortar and the inner bark of some trees, which is the immediate effect
of the action of corrosive sublimate upon the serum. The serum that had
come through the dressing equally resisted the inoculation. By means of a
process of testing with which I will not now trouble the Society, I could ascertain
pretty exactly the proportion of corrosive sublimate present in these liquids
that had thus come through. The corrosive sublimate made the liquids turbid
in the case of the wool with stronger proportions ; but, in the case of the I per
cent., it had not rendered the serum turbid, and therefore I was able, without
the use of the microscope, to judge by the existing transparency, and also by
the presence or absence of scum on the surface, whether any organisms did or
did not develop ; and none whatever occurred. As regards the strongest wool,
the liquid which came through contained about one part of corrosive sublimate
to 160 parts of the fluid. I tasted this, and found it had the peculiar metallic
nauseous taste of corrosive sublimate. I also mixed some of it with five parts
of milk got from a dairy, and therefore, as we know, containing bacteria of
various kinds. Here is the milk, still fluid after the lapse of nearly six weeks,
although, when it was mixed with the serum, it was already advancing towards
septic changes. The first of those changes, namely, lactic fermentation, has
been prevented, otherwise the milk would not have been fluid, as you see it
tobe. There is not the slightest smell either of the lactic or butyric fermentation,
but only that which Pasteur pointed out to occur as the result of oxidation
of the fatty matter of milk—a little odour of suet. That is exactly the smell
that you have in boiled milk kept for a few weeks in an aseptic state.
Thus, Mr. President, we had evidence that corrosive sublimate forms,
with the serum of the blood, a material, whether we call it a chemical compound
or not, which retains the properties of the corrosive sublimate, both as to taste
and as to antiseptic virtue. Now it seems to me highly unlikely that both the
characteristic taste of corrosive sublimate and the antiseptic virtue would be
retained if the corrosive sublimate were decomposed in any way; and therefore,
I venture to think, speaking with all deference to chemists, that we have not here
a chemical combination in the ordinary sense, but an association of particles,
such as occurs in solution : not an albuminate of mercury, but an albuminate of
sublimate, if I may use such an expression ; a loose association of particles of
chloride of mercury with albumen. If such be the case, I need hardly point out
how important this may be with reference to the surgical uses of corrosive
sublimate. The discharges, in passing through a sublimate dressing, may acquire
AS A SURGICAL DRESSING 303
from that dressing chloride of mercury, still in solution, though associated with
albumen, and still retaining antiseptic properties.
I may conclude this matter of the relations of the blood-serum to corrosive
sublimate by showing some illustrative specimens. I found that, if serum is
mixed in small proportions with corrosive sublimate, in a mortar, the result
is the production of a thick, opaque, slimy material; but if you add a little
more, and still a little more, you get this material redissolved in the serum,
until, if you use as much as 150 parts of serum to one of sublimate, you get
a clear solution. This test-tube contains serum from the blood of a horse,
mixed with one two-hundredth part of corrosive sublimate. You will see that
there is no precipitate here at all. This other test-tube contains the same
amount of corrosive sublimate (1 to 200) ; but the liquid mixed with it, instead
of being serum simply, is serum with an equal part of distilled water; and
here we have what the chemists describe as a precipitation of the albumen,
the upper part of the liquid being clear. Now, this upper part of the liquid
contains exceedingly little corrosive sublimate; it has almost all gone down
with the albumen ; but if we take some of this precipitate itself and mix it with
more serum, it will be redissolved by that serum. This afternoon, I mixed some
of this precipitate with some serum already containing one four-hundredth
part of sublimate, and the result has been the clear solution that you see here.
This albuminate, if we are to call it so, is therefore highly soluble in blood-serum,
and that is one important point to which I wish to direct attention.
While the sublimate is thus, so to speak, intact when associated with
albumen, it is rendered very much milder in its action. I took some of the
serum which had come through the Io per cent. wool, containing one part of
corrosive sublimate to 160 parts liquid, soaked a piece of lint with it, and applied
it tomy arm, put over this a piece of thin macintosh cloth, to prevent evaporation,
and secured this with rubber adhesive plaster. I retained this dressing in position
for twenty-four hours, and on its removal found an absolute absence of any
irritation, although my own skin is pretty sensitive. We have seen how, in
twenty-four hours, one part of sublimate to 500 of water already produced
pustules ; yet here one part to 160 of serum produced no irritation whatever.
The association, then, of the albumen with the corrosive sublimate greatly
mitigates its action, and makes it much less irritating. Thus we are able to
understand how the discharges coming from a wound soaking a sublimate
dressing may not cause irritation, although the dressing may contain a large
proportion of corrosive sublimate. Such being the case, I hoped that we might
be able to use corrosive sublimate in pretty strong proportions in a gauze for
the dressing of wounds; and therefore, not very long ago, in a case Of psoas
304 AN ADDRESS ON CORROSIVE SUBLIMATE
abscess, I applied gauze containing 5 per cent. of corrosive sublimate, with
a little gum arabic to prevent the crystals flying off. On changing the dressing
the following day, I saw in the vicinity of the wound all perfectly satisfactory ;
but, the discharge having gone principally backwards, I found that the further
I looked towards the sacrum the more and more evidence of irritation did I find,
until over the sacrum itself, beyond the edge of the dressing, there was absolutely
a large vesicle. How was that to be explained? The explanation I believe
to be simply this. If an albuminous discharge travels through a dressing con-
taining corrosive sublimate only, it, in the first instance, forms, with the corrosive
sublimate, a non-irritating albuminate, so to speak, but leaves more or less of
its albumen behind in the form of a precipitate. As it goes further, and meets
with more corrosive sublimate, it leaves more albumen behind, and so, as it
advances, becomes more and more nearly a watery solution of corrosive sublimate,
producing the highly irritating effects with which we are familiar. This result,
I confess, made me at first despair of using corrosive sublimate in anything like
a concentrated form as a surgical dressing. But it afterwards occurred to me,
might it not be possible, as corrosive sublimate associated with albumen is so
little irritating, to associate albumen with the corrosive sublimate in the dressing ?
Where should we get our albumen from? Well, we may get it from horse’s
blood. There are in every town horse-slaughterers. If you stir horse’s blood
while it is coagulating, you may get from one animal some gallons in the form
of serum. There is the albumen for you, if only it can be made useful. There
is a horse-slaughterer in the north of London who will let us have this serum
absolutely for nothing ; it is simply a useless material to him. This being so,
I ascertained in what proportions the serum and the sublimate might be mixed,
so as to give a workable article ; and I find that you may employ them in almost
any proportions. If you use a very small amount of serum, you get, indeed,
a thick opaque substance; but this can be perfectly well blended with gauze
or other materials. Here is a gauze which has been charged with serum con-
taining one part of corrosive sublimate to seventy-five. Two and a half parts
of the liquid are required for charging one part of the gauze; and you will see
that this is not at allan unpleasantly constituted substance, physically. It is
destitute of odour; you will scarcely perceive it to the taste; and you would
hardly believe that it contained nearly three parts per cent. of corrosive
sublimate.
The corrosive sublimate is so intimately blended with the serum that,
when it dries (as seen on this plate of glass), no separation of crystals takes
place. Whether we use I to 100, I to 70, I to 50, or even I to 30 parts of blood-
serum, they are perfectly amalgamated, and therefore, from a gauze like that,
AS A SURGICAL DRESSING 305
no corrosive sublimate can fly off. It can be manipulated as you please, and,
as applied dry to the skin, it is absolutely unirritating.t Then, in the next
place, it is unirritating as acted on by the perspiration. If water is made to
act on sublimated serum dried, it does not redissolve it as serum does, but it
renders the mass opaque, the water being only partly absorbed into it; and
the water which remains unabsorbed contains exceedingly little of the corrosive
sublimate, which is almost all retained by the albumen. Hence, when per-
spiration soaks into such a dressing, though it moistens it, it does not produce
irritation. I made some gauze with serum so strong with corrosive sublimate
as to have I part to 30, which implies more than 6 per cent. of corrosive sublimate
in the dried gauze. I moistened a piece of this with distilled water, and fixed
it on my arm for six hours in the manner above described ; and, when I removed
it, I found the skin free from irritation. Thus, you will observe that, by asso-
ciating albumen with the corrosive sublimate, we seem to be able to get md
of its irritating properties.
But the important question arises, Does corrosive sublimate, when thus
associated with albumen, retain sufficient antiseptic virtue for surgical purposes ?
The method of experimenting which I have described is adapted for testing
the efficacy of any antiseptic dressing, and I have used it for various others
besides sublimated ones. I have employed it for salicylic cotton-wool, for
iodoform cotton-wool, for eucalyptus gauze, and for carbolic gauze. I have
mentioned that the test is an exceedingly severe one, and I find that, after
the lapse of a few weeks, salicylic wool soaked with serum and inoculated as
above described, stinks; and the same is the case with iodoform wool. The
eucalyptus gauze, however, if freshly prepared, remains pure; as also does
carbolic gauze. We have seen that the I per cent. sublimate-wool resisted,
still more the 5 per cent. and the ro per cent. In accordance, therefore, with
our previous experiments with i1odoform and salicylic acid, they did not stand
the test as well as carbolic acid, or eucalyptus, or the corrosive sublimate. But
we get a different result if, instead of using serum of blood, we use serum mixed
with blood-corpuscles, such as we readily get from the cow, in which the
corpuscles do not aggregate so closely as in the horse, but remain suspended in
the serum. I need not, of course, tell any members of this Society, that the
corpuscles are enormously richer in protein substances than the serum is, so
that serum and corpuscles contain about 24 times as much of proteid material
as the serum does; and as albuminous materials mitigate the action of the
corrosive sublimate, they cannot fail to interfere more or less, also, with its
1 Tf such a gauze be torn, it gives off a dust which irritates the nostrils. It is, therefore, better
to cut it with scissors.
306 AN ADDRESS ON CORROSIVE SUBLIMATE
antiseptic action ; and when we use serum and corpuscles, instead of serum
only, we find that the sublimated wood-wool (which I should have said did
very well with the serum so far as the sense of smell indicates) fails completely.
The 1 per cent. sublimate-wool failed also; the Io per cent., however, stood
the test perfectly, even with blood in substance. Now, as to our gauze made
with albumen associated with the sublimate, the sero-sublimate gauze. Such
a gauze, prepared with I part of sublimate to I0o of serum, stood the test
absolutely when tried with serum. It therefore proved itself superior to salicylic
and to iodoform wool. But with the blood in substance, how does it behave ?
The tube in this bottle contains a portion of the gauze treated with the cow’s
blood, serum and corpuscles, and inoculated nearly a month ago in the same
potent manner to which I have referred, and you will observe that it has no
putrid odour. Really, then, this sero-sublimate gauze seems to stand the test
completely. I may say that, when tried with corpuscles and serum, our best
eucalyptus gauze failed utterly, so that everything that I have tried failed with
serum and corpuscles, except the stronger sublimate preparations and carbolic-
acid gauze.
Then the question comes, how far may we go in the strength of our sublimate
combined with the albumen without causing irritation ? During the last three
weeks, my cases at the hospital have been dressed with this material. We have
used the kind of gauze which was tested in the above experiments, made with
I of sublimate to 100 of serum, and also one made with 1 of sublimate to 50 of
serum. We find that the 1 to 50, in the majority of cases, has caused no irritation
whatsoever, but in a very few it has caused some irritation, which, however,
has disappeared, and the sores caused by the I to 50 have healed when the
1 to 100 has been substituted for it. Therefore it looks as if we were very near
our limits, as if that prepared with I of sublimate to 100 of serum was trust-
worthy and unirritating, even to all skins, and that prepared with 1 to 50 was
unirritating to most skins. Now there is this to be observed for our comfort,
that the discharge both from wounds and from abscesses antiseptically treated
is a serous discharge, not a bloody one, except in the case of wounds during the
first twenty-four hours; and even in the first twenty-four hours, except in
cases in which the dressing has to be taken down for reactionary haemorrhage,
the blood is always more or less diluted with serum. If, therefore, we have
a dressing which has stood our severe test with serum mixed with the full amount
of corpuscles, we are surely right in regarding it as trustworthy.
Last Friday, I amputated at the hip-joint in a boy twelve years of age, on
account of a sarcoma of the lower half of the femur. The wound was exceedingly
vascular, and there was a great deal of bloody oozing in the first twenty-four
AS A SURGICAL DRESSING 307
hours, but very little blood escaped externally, because this gauze absorbs very
much better than our carbolic-acid or eucalyptus gauzes do, containing as they
do resin and paraffin; and I would strongly recommend that, during the first
twenty-four hours, this gauze should be used in at least sixteen layers. It is
now three days since the operation was performed, and, from the perfectly
normal temperature and returning appetite and strength, I think we may be
satisfied that the boy is already out of risk of septic complications. And this
you will observe, is a very testing case.
I may mention one other case, that of a boy six years old, from whom,
nearly three weeks ago, I removed a portion of a rib, for the purpose of allowing
free drainage to empyema. We let out thirty ounces of thick, odourless pus,
and a great quantity came out afterwards. He has been dressed with sero-
sublimate gauze ; and he is one of the instances in which gauze prepared with
the 1 to 50 serum caused irritation, which disappeared under the 1 to roo.
In him we have witnessed the beautiful course which, I believe, we can
only see under antiseptic treatment efficiently managed, of no more pus formed
after the first pus has been evacuated—nothing but a serous oozing rapidly
diminishing ; and I was delighted to see, on coming back after a fortnight’s
absence, how plump the emaciated little fellow had become. And the serous
discharge is now so slight, that I believe it would be already safe to remove
the drainage-tube. This case, I think, proves that our dressing is aseptic,
that the germicidal properties of the corrosive sublimate have come into play
in the preparation of the dressing, so that any injurious organisms which existed
in the blood or in the gauze before they were brought into preparation, have
been destroyed: because, if there had been merely the inhibitory influence
of the sublimate upon the organisms, the serum pouring out from the pieura,
washing away all the antiseptic in the vicinity of the wound, but leaving the
organisms lodging among the fibres, then we should have had putrefaction, or
other disturbing causes, showing themselves. No such thing having occurred,
this case seems of itself sufficient evidence that our dressing is really a safe one
in so far that it contains no living organisms of importance to start with.
I have here a sample of a very cheap fibre, sent me from the south of France,
prepared with this sublimate-serum, and then teased out, showing that we may
use this material for charging various fabrics. This fibre is highly absorbent ;
and I may remark that, if we have a very highly absorbent dressing, we may,
and must, use a larger proportion of the sublimate. A gauze will absorb only
about three times its weight of liquid; cotton-wool will absorb ten times its
weight ; and therefore you observe, when the one dressing is saturated, it has
three times as much of the liquid in it, and thus has the sublimate three
308 “ON CORROSIVE SUBEIMATEVAS A) SURGICAL DRESSING
times as much diluted. Being so much diluted, it will be in proportion less
irritating, but a stronger proportion is required to make it safe unless you use
it in a very large mass. I believe the French charpie, made of old rags,
or even old rags themselves, might be quite well prepared with sublimated
serum. I have here some rags which have been so treated, and which are quite
absorbent, and therefore the dressing promises to be a very cheap one. If the
serum is treated with a certain proportion of sublimate, not sufficient to make
it solid, it may be kept for any length of time. For aught I know, this sublimated
serum may come to be an article of commerce, which may be used in hospitals,
or even in private practice. I also think it possible that a material of this kind,
dried and reduced to powder, may come to be used for the purpose of mixing
with vaseline for an antiseptic ointment, or even for dusting in, under certain
circumstances, among our dressings.
I regret that time has not allowed me to bring this matter more completely
to an issue as regards its practical applications. At the same time, though
the subject is, to a certain extent, immature, I ventured to hope that the interest
of some of the points to which I have referred might justify me in bringing it
before you.
AN ADDRESS ON A NEW ANTISEPTIC DRESSING
Delivered before the Medical Society of London, November 4, 1889.
[Lancet, 1889, vol. 11, p. 943.]
Mr. PRESIDENT AND GENTLEMEN.—When I last had the honour, five
years ago, of addressing this Society at the request of its President, I brought
before you an attempt I had made to utilize the powerful antiseptic properties
of corrosive sublimate without the great disadvantages attendant upon its
highly irritating qualities.1. I had ascertained that when corrosive sublimate
precipitates albumen the precipitate is not, as had been generally supposed,
an albuminate of mercury—that is to say, a combination of albumen as an
acid with mercury as a base; in other words, that the albumen does not displace
the chloride from its combination, but that the bichloride of mercury retains its
properties intact, the albumen being loosely associated with it, in a species of
solid solution, 1f I may so speak.
Further, I had found that this precipitate, even after drying, is capable
of being dissolved in the serum of the blood, and that the solution in blood-
serum is powerfully antiseptic while not irritating. I proposed and brought
before you a new dressing in the shape of what was termed the sero-sublimate
gauze, charged with a solution of corrosive sublimate in the serum of the blood.
This gauze gave very satisfactory results, both in my own hands and in those of
surgeons in places so far distant as Poland and Spain. Nevertheless, it was not
all that could be desired by any means ; it was somewhat harsh mechanically ;
it was not very absorbent (a serious defect), and one of the materials of which
it was made (the serum of horse’s blood) was not always easily obtainable.
I was, therefore, well disposed to look for something superior.
A few weeks after that communication was made to the Society, a firm
of manufacturing chemists, Messrs. Gibbs, Cuxson & Co., wrote to me saying
that they had found that if chloride of ammonium or sal ammoniac in quantity
equal to one-fifth part of the weight of the bichloride of mercury was added
to the mixture of bichloride of mercury and blood-serum, the result was a much
more fluid preparation than I had obtained. If I used a preparation of one
part of bichloride of mercury to 100 of blood-serum, I got a thick liquid some-
what difficult to diffuse in gauze. They therefore suggested that by adding
‘ See p. 293 of this volume.
310 AN ADDRESS ON A NEW ANTISEPTIC DRESSING
sal ammoniac in that proportion I should get a much more workable arrange-
ment. On consulting chemical works I found that one-fifth of sal ammoniac
was exactly sufficient to produce with bichloride of mercury the salt long known
to chemists as sal alenibroth, a double salt of bichloride of mercury and chloride
of ammonium. I naturally wished to ascertain whether this addition of sal
ammoniac would impair or even destroy the antiseptic properties of the bichloride
of mercury. I therefore made experiments on the point, and I found that the
sal ammoniac associated in the form of a double salt with the bichloride of
mercury did not by any means impair its antiseptic properties ; on the contrary,
it improved them, so far at least as concerned that which we have to deal with
as surgeons, an albuminous fluid like the serum of the blood. Sal alembroth
and bichloride of mercury proved to be exactly equivalent weight for weight as
antiseptics in such a fluid. Each had to be used in normal serum of specific
gravity of about 1,025 in the proportion of about I-1,oooth in order to prevent
altogether the development of micro-organisms. Those who are acquainted
with Koch’s researches will consider this a very high proportion. Koch has
shown that in a solution destitute of albumen 1-100,000th part of bichloride of
mercury is sufficient to prevent the development of organisms; but when we
have albumen present in the solution the case becomes altogether altered.
Albumen interferes with the antiseptic action of corrosive sublimate, and thus
in serum of the blood of specific gravity 1,025 we require, as I have already said,
as large a proportion as about I-1,o0o0th instead of I-100,000th.
When the albumen is small in amount, less corrosive sublimate proves
efficient. Thus, in a case of spermatocele, where the specific gravity of the
fluid was exceedingly low—only 1,0o07—I found that 1-1,oooth, just intermediate
between the proportions required for blood-serum and water, was efficacious.
On the other hand, when blood-corpuscles are mixed with the serum in the same
amount as in the circulating blood, making the albuminoid substances much more
abundant than in serum, we require proportionately more of the corrosive
sublimate ; at least I to 500 is required for the purpose of preventing develop-
ment. This is a most important consideration after an operation. In the first
twenty-four hours the discharge contains a large amount of blood-corpuscles as
well as the serum ; whilst, at the same time, it is the most copious—more copious
than it will be in any subsequent day, provided all goes well aseptically. It is
therefore, an exceedingly serious consideration that in the first twenty-four
hours we have a discharge which in both these respects tests our antiseptic
more severely than it will ever be tested again, both from its abundance and
from its quality. Still, the sal alembroth, whether used with blood-serum or
with a normal mixture of serum and corpuscles such as that obtained by
AN ADDRESS ON A NEW ANTISEPTIC DRESSING SEE
whipping the blood of the ox so as to get rid of the fibrine, proved equivalent
antiseptically to bichloride of mercury.
I may perhaps say in a few words how the experiments were conducted.
For the purpose of ascertaining whether a given antiseptic can or cannot prevent
development of organisms, a very simple mode of experimentation suffices.
What we have to do is to ascertain whether it is inhibitory, not whether it is
germicidal. The only special apparatus required for such experiments is a warm
chamber which can be kept pretty constantly about the temperature of the
human blood. Beyond this a few stoppered bottles, with well-fitting stoppers—
perhaps half-ounce stoppered bottles—are really all that is required. Into
a series of such bottles serum of the blood, to the amount, say, of I50 grains,
containing solutions of the antiseptic of different strengths, is introduced.
These are all inoculated by means of a small syringe pipette with the same
quantity, say, I-1oth of a minim, of some potently septic liquid, such as blood-
serum in a state of advancing putrefaction. The bottles are placed in the
incubator, and then, if development takes place, that is evidence that in the
bottle in which it occurs such proportion of the antiseptic as that bottle contains
is inadequate ; if no development occurs, we have proof of antiseptic efficacy.
The transparency of the serum permits a recognition of the development of the
organisms, which invariably causes opacity. If we have no change in this
respect, if the serum maintains its transparency, at the same time keeping its
odour unimpaired, and, further, if microscopic examination of any little sediment
there may be shows that it contains no organisms, we have clear evidence that
the antiseptic in the proportion concerned has proved efficacious.
Now if the sal alembroth was equivalent to the bichloride of mercury,
weight for weight, that shows that the sal alembroth was really more efficacious
as regards the quantity of bichloride of mercury it contained. The bichloride
of mercury having the sal alembroth added to it, and also water in the double
salt that is formed, is increased in atomic weight very considerably ; and there-
fore if an equal weight of alembroth is equivalent in antiseptic action to bichloride
of mercury, that shows that the bichloride of mercury is made more efficacious
in the blood-serum by the addition of the chloride of ammonium. The chloride
of ammonium in combination protects the bichloride of mercury, so to speak,
to a certain extent, from the interfering influence of the albumen.
At the same time, the sal alembroth proved much less irritating than
bichloride of mercury. Experimenting on my own skin, I ascertained that it
has certainly not half the irritating property of corrosive sublimate. The
chloride of ammonium attached to the bichloride of mercury, while it protects
the bichloride in some degree from the influence of albumen interfering with
312 AN ADDRESS ON A NEW ANTISEPTIC DRESSING
its antiseptic operation, prevents it also from acting so powerfully on the human
skin. And thus the union of sal ammoniac with corrosive sublimate had the
double advantage of rendering it both more efficacious antiseptically and much
less irritating.
Hence I was at first much pleased with sal alembroth. But it soon appeared
that there were certain disadvantages attending it. These depend very much
upon its excessive solubility. It is essential for a satisfactory antiseptic dressing
that the antiseptic should not be readily washed out of it by the discharge.
Sal alembroth is so exceedingly soluble that it is washed out with the greatest
ease ; thus we were always, even if we used large masses of sal-alembroth gauze,
in fear that when the discharge was copious the antiseptic would disappear,
say, within the first twenty-four hours, and then the septic mischief would
have an opportunity to enter. There was another disadvantage from this
great solubility. When the discharge entered a mass of the sal-alembroth
dressing it dissolved out the alembroth from it, passed into another part of
the dressing, and there took up another portion of the sal alembroth, and so
went on from part to part of the dressing, until, if the discharge was copious
and the dressing large, as it must be when the discharge is copious, before the
discharge got to the edge of such a dressing it became so concentrated a solution
of the sal alembroth as to be highly irritating. We have seen, for instance,
after the removal of the mamma, when the first dressing was changed on the
following day, that there has been over the scapula and the neighbourhood
a huge blister. No doubt that was only a temporary inconvenience. We never
had the discharge again so great as in the first twenty-four hours, but still it
was a great inconvenience.
Such being the disadvantages of sal-alembroth dressing, I was disposed
to seek for something better. I may say that I myself have never published
anything in favour of sal-alembroth dressings ; I have never been satisfied with
them. It has leaked out that I have used them, and they have come into
extensive employment, but never with my published sanction.
In the course of the following year I made various experiments in the hope
of rendering sal alembroth more useful in different ways, with which I need
not trouble you, but without much success. In February 1886 my attention
was drawn by Mr. Martindale of New Cavendish Street, to cyanide of mercury
as possibly a valuable antiseptic, and, if so, having this advantage, that it did
not coagulate albumen. I therefore proceeded to make experiments with
cyanide of mercury, and I found, indeed, that in inhibitory power it was remark-
ably efficacious. I have said that with blood-serum sal alembroth or bichloride
of mercury is required in about 1-1,oooth part. I found that the cyanide of
AN ADDRESS ON A NEW ANTISEPTIC DRESSING 313
mercury kept blood-serum with only I-10,o00th part perfectly free from organic
development, in spite of inoculation with potent septic fluid, for a month, when
the experiment ended. I may remark that we have in the cyanide of mercury
a striking instance of the discordance that there may be between inhibitory
power and germicidal power in an antiseptic. In inhibitory power the cyanide
of mercury is, as we have seen, exceedingly high ; but in germicidal power it
turns out to be very low. Mr. Cheyne has made experiments for me, which
have shown that even I-1,oooth part in water is incapable of destroying the
germs of bacteria. Still, the inhibitory property of cyanide of mercury was
a most important point if in other respects the salt were not disadvantageous ;
but, unfortunately, it proved to be so highly irritating that the greater irritating
property of the cyanide of mercury more than counterbalanced its superior
inhibitory power. It naturally occurred to me that the cyanide of mercury
might perhaps combine with some other cyanide and form a double salt, having
advantages corresponding with those presented by sal alembroth as compared
with bichloride of mercury. I tried the soluble double cyanide of mercury and
potassium, but found it quite too irritating. I here again consulted Mr. Martin-
dale, and he mentioned to me that in Watts’s Dictionary of Chemistry it is stated
that a double cyanide of mercury and zinc of very slight solubility may be
formed by mixing together a solution of the double cyanide of mercury and
potassium with a soluble salt of zinc, the zinc taking the place of potassium.
I therefore obtained some of this material, and proceeded to make experiments
on it. I found, in the first place, that it was quite insoluble in water. This
seemed at first extremely unpromising. It was soluble in about 150 parts of
glycerine, but insoluble in water. I found, however, that it was soluble in
about 3,000 parts of blood-serum, and therefore it was possible that it might
work antiseptically. I made experiments to ascertain whether such was the
case or not, and I found that this zinco-cyanide of mercury, as we may call it,
had really most important antiseptic properties; that in the proportion of
I-5,000th part it kept blood-serum perfectly free from the development of
organisms for eighteen days, in spite of potent septic inoculation.
I then tried experiments with serum and blood-corpuscles as presented in
the whipped blood of the ox. On instituting comparative experiments between
sal alembroth, cyanide of mercury, and this double cyanide, I found that with
the alembroth all proportions lower than 1—4ooth putrefied within twenty-four
hours after septic inoculation, while with the cyanide of mercury 1-Sooth part
sufficed to preserve the serum and corpuscles from putrefaction. At the same
time, with the double cyanide I was much surprised and much pleased to find
that 1-1,200th, half as little again, was sufficient to keep the mixture of serum
LISTER II a
314 AN ADDRESS: - ON Ao NEW ANTISEPTIC DRESSING
and corpuscles permanently free from putrefaction. It may be said that the
absence of putrefactive odour is but a rude test. There may be organisms
developed without any putrefactive odour being present; that is perfectly
true. At the same time, if in a given experiment we find that with one agent
putrefaction occurs within twenty-four hours with I-4o0o0th part, while with
another salt there is no putrefactive odour after the lapse of weeks with 1-1,200th
part, we have pretty conclusive evidence that, so far as the mixture of corpuscles
and serum is concerned, you have a more efficacious antiseptic in the latter.
I therefore proceeded to prepare dressings of this new substance, diffusing it—
for it is an exceedingly fine powder—in water with a little glycerine added to
fix it, to prevent it from dusting out. If you simply diffuse it in water, and
pass gauze through it, with nothing more than the water, the result is that you
have gauze which, with the shghtest touch, gives out the double cyanide in a
cloud of dust, which produces not only inefficacy of your dressing by loss of
the proper proportion of the substance, but becomes in the highest degree
irritating to the nostrils of those who are near. A little glycerine, however,
prevented the double cyanide from thus dusting out. I proceeded to try it in
practice. I confess I did not dare to use it—considering its very slight solubility
in serum—unmixed, and I associated with it some of the very soluble cyanide
of mercury ; and with this cyanide gauze we tried various experiments in the
way of dressing, and got some admirable results. But then, on the other hand,
there were disappointments. We found, for one thing, now and then very
troublesome pustules as the result of a peculiar kind of irritation. Another
disadvantage was that occasionally we got suppurations, coming on at a late
period in the case, such as we had never been accustomed to with our carbolic
dressings. A case might go on perfectly well for, say, ten days, and then
suppuration might occur about a stitch track and spread perhaps further ;
and sometimes the healing of cases was greatly protracted by this late suppura-
tion. In consequence of these two circumstances I gave up the use for the
time being of this material.
I then directed my attention to biniodide of mercury, which has been
highly spoken of for its antiseptic powers, and which has the advantage over
alembroth of being comparatively little soluble either in water or in serum.
I found that the iodide-of-mercury gauze answered our purpose very well so far as
its antiseptic properties were concerned, but that it had the great disadvantage
of producing irritation, which it was extremely difficult to control. In order
to control it, we interposed between the iodide-of-mercury gauze and the skin
unprepared gauze, except in so far as it was steeped in a weak solution of
bichloride of mercury (1 to 4,000). But we found that different skins differed
AN ADDRESS ON A NEW ANTISEPTIC DRESSING 315
greatly in liability to this irritation. The iodide of mercury, which is so very
slightly soluble, as you know, in water, is much more soluble in serum, and the
solution in blood-serum becomes irritating. In consequence of this, we had
the same disadvantages from irritation as we had with the alembroth; and
although, as in the case of the alembroth, this was only a transient inconveni-
ence, I became dissatisfied with the iodide-of-mercury gauze. There was,
however, one point of considerable interest, both theoretically and (as it turned
out afterwards) practically, which we found in this investigation with the iodide
of mercury. If we simply charged with iodide of mercury, say, from a solution
in spirit of wine, and then applied the gauze so prepared, we found that the
particles of iodide of mercury tended to gravitate down towards the skin, and
there produce the most fearful irritation. It was absolutely necessary that
it should be fixed. I tried various means, and among the rest a solution of
starch, and then there came out this remarkable fact, that if a solution of starch
is used with one of the ingredients employed for forming the biniodide of
mercury by mixing a solution of iodide of potassium with solution of bichloride
of mercury—if you dissolve the iodide of potassium in a weak solution of starch
—the iodide of mercury thus formed in the nascent state associates itself
with the starch particles in the most intimate manner, and the starch becomes
entirely precipitated along with the iodide of mercury. If you take a drop of the
red fluid formed by mixing these two solutions, and place it on a piece of calico,
the watery material is absorbed by the calico and passes into the surrounding
parts without colouring them, while the red spot with its insoluble iodide
remains. If now you take a little iodine water, and apply it to the part of the
calico moistened by the fluid that has exuded, you find that the iodine water
produces no blue colour of iodide of starch, showing that there is no starch in
the fluid that thus oozes out and leaves the iodide of mercury behind ; whereas,
if you take a solution of starch and apply it as such to a piece of fabric, as far
as the fabric becomes moistened so far do you get a blue colour with the iodine.
Here we have, as it seems to me, a somewhat analogous case to the so-called
albuminate of mercury. We have the starch particles associated with the
particles of iodide of mercury ; the starch remains as such, the iodide of mercury
remains as such, still they are attached to each other. And so the result was that
when such a red solution produced by these two liquids was used for charging a
gauze, the iodide of mercury was stuck to the gauze by means of the starch, and
we had a most satisfactory arrangement in that respect. The iodide of
mercury could not be washed out by water, nor did it in the least dust out. The
value of this observation with reference to our present subject will appear shortly.
Being dissatisfied with the iodide of mercury, I turned my attention again
Y2
316 AN ADDRESS ON A NEW ANTISEPTIC DRESSING
to the double cyanide of mercury and zinc. Looking back to my notes, I found
such evidence of its superior antiseptic properties that I felt that we had deserted
this material too readily. In the interval we had had other experience of
importance with the alembroth gauze. Occasional late suppurations had at
first occurred under its use, just as was the case with the double-cyanide gauze.
These, however, had ceased to trouble us after my attention had been directed
to the expediency of always using mercurial dressings in a moist condition.
If they are used dry, the mercurial salt having no volatility, and having no
power, therefore, of destroying any micro-organism in contact with it, whether
derived from the manufactory or elsewhere, there could be no security that the
dressing when applied was free from living organisms. This important object
could, however, be infallibly attained if the dressing were used moist with an
efficient germicidal solution. I put this idea into practice, and during the two
years that have since elapsed we have never on any single occasion had to com-
plain of these late suppurations. Might not the same immunity attend our
cyanide gauze if we adopted with it the same expedient ?
The other objection to this double-cyanide gauze had been the irritation
which it occasioned. Might not this have been due to the simple cyanide, which,
as I have said, I used along with the double cyanide ? The simple cyanide is
highly irritating, and just as with the sal alembroth, being freely soluble, it
can be taken up by successive portions of discharge, and, when the discharge
is free, may come to be in so strong a solution as to irritate. On the other hand,
experiments on my own person had shown that the powder of the double cyanide
might be kept applied to the skin for an indefinite time, whether moistened
with water or with blood, without occasioning any irritation whatever. If
this was really the explanation, and if, as our experiments seemed to indicate,
the double cyanide could be trusted of itself, we might easily get rid of all
irritation by using a double-cyanide dressing moistened with a weak solution of
bichloride, say, I to 4,000, which, while it is securely germicidal, can never
irritate. But here arose a new difficulty. I have told you that when we tried
this double cyanide in a gauze at first, in order to prevent the dusting out,
with its great inconveniences, we used glycerine; but if we were to moisten
the gauze with 1 to 4,000 solution of corrosive sublimate, we should run great
risk of washing out the glycerine, and then the double cyanide would be free
to dust out on drying. And, besides that, it must be admitted that the glycerine
arrangement was not a good one, independently of that consideration, inasmuch
as when the discharges flowed into the gauze they would wash away the glycerine,
and then the double cyanide might be washed out also, and so fail in one of the
most important requisites of an efficient antiseptic dressing—the storage of the
AN ADDRESS ON A NEW ANTISEPTIC DRESSING 317
antiseptic in the dressing in spite of the discharge. How was this difficulty
to be overcome ?
Now came to our aid our experience with the iodide of mercury and the
starch. Might it be that the particles of the double cyanide would attract
starch as those of the iodide had done? It did not seem very likely, seeing
that cyanogen is not known to have the special affinity for starch that iodine
has. Still, I thought I would try the experiment. I prepared the double
cyanide by mixing a solution of the double cyanide of mercury and potassium
with a solution of sulphate of zinc. I tried this with one of the ingredients
dissolved in a starchy solution, and, to my great satisfaction, I found that the
precipitated double cyanide left a supernatant liquor almost absolutely free
from starch, and that the particles which thus fell, the double cyanide with the
starch associated, fixed themselves to a gauze in such a way that it did not
in the least dust when dry. Not only so, but immediately after being charged
with the precipitate diffused in water it might be washed in the wet state without
the double cyanide being washed out of it, so closely did the starchy particles
stick the double cyanide to the fabric. It is of great importance that in some
way or other the double cyanide should be washed, because at the same time
that an insoluble double cyanide is formed there are produced other double
cyanides which are soluble, and which are in the highest degree irritating ;
they must be washed out.
Well, I thought I had thus attained my object, and that by mixing starch
with one of the two solutions necessary for forming this double cyanide and
allowing the precipitate to deposit itself, then pouring in more water, and,
after precipitation, decanting and repeating the process another time, so as to
get rid of all the irritating soluble salts, and then diffusing the precipitate through
a gauze, I should have all that I desired. But when I tried to get this done by
a manufacturer I found that I got blundering after blundering in such a way
as to make the thing practically hopeless. There was nothing for it but in
some way or other to get the double cyanide from the chemist as a definite
article, and then in some way devise a means of fixing that powder of the double
cyanide to the fabric. I therefore naturally tried whether a solution of starch
would answer this purpose, whether the starchy particles would associate them-
selves with the double-cyanide particles, not only in the nascent state, which
we had before tried, but also when the already formed double cyanide was mixed
with the starchy solution. I found that it did so; that when a starchy solution
was stirred up with the double cyanide in the proportion of one part of starch
to two of cyanide, the starch was almost all precipitated, and the precipitate so
formed adhered to the gauze in the most satisfactory manner.
318 AN ADDRESS ON A NEW ANTISEPTIC DRESSING
But, though its adhesion was satisfactory enough, it turned out that the
precipitate thus formed aggregated into a tenacious mass, which could not be
diffused uniformly through the gauze, and here I was again at fault. This
difficulty was overcome by first charging the gauze with the double-cyanide
powder diffused in water, and then transferring it to a starchy bath. This at
once fixed the cyanide in the gauze ; and, whereas, before it was placed in the
starchy bath, the slightest squeeze made a milky fluid exude, no sooner had it
been well penetrated by the starchy liquid than you might squeeze it as you
pleased, and nothing came out but a clear fluid. I was much pleased with
this, and it is in this way that I have prepared the gauze that I have used for
the last twelve months, both in the hospital and in private practice. Still,
this method had its disadvantages. When the gauze had been passed through
the fluid in which the double cyanide had been diffused without any starch,
it required very tender handling. If you gave it a squeeze, out came a quantity
of double cyanide; and it was plain that, although one might do it oneself
satisfactorily, if we trusted to the manufacturers there would be an utter un-
certainty as to what quantity of material might ultimately remain in the gauze.
Only lately has this difficulty been surmounted. It occurred to me that
perhaps if the starch were first blended with the double cyanide and then dried
and reduced to powder, if water were afterwards added to this dried dissolved
starch associated with the cyanide, there might not be the same tendency to
lumpiness and difficulty of diffusion. I found that the process did not answer
quite as I hoped in the first instance, in this respect; that the dried starch
and double cyanide were extremely difficult to scrape off from any plate on which
they were put to dry, and also very difficult to pound up and to diffuse for
charging the gauze. But I got rid of these inconveniences by means of sulphate
of potash, used for the same reason as in the preparation of Dover’s powder—
viz. that it is an inert substance, but with sharp, gritty particles. Mixing
a pretty strong solution of starch with the double-cyanide powder, and adding
to this a quantity of pounded sulphate of potash, the result is that you get
a material which, after drying, is easily scraped off by the manufacturer, and
easily reduced by him to an impalpable powder, which is then readily diffused
in water, and makes a perfectly uniform gauze ; being mixed in large quantity
with water in order to charge the gauze, the sulphate of potash is practically
got rid of, and if any of it remains it does no harm, because it is inert. Thus
we have the means of easily charging fabrics with this double cyanide.
I have spoken of diffusing this preparation in water, but in reality we
employ for this purpose the 1 to 4,000 solution of bichloride of mercury, which
fortunately does not in any way interfere with the process. I may remark
AN ADDRESS ON A NEW ANTISEPTIC DRESSING 319
that the double cyanide, like the simple cyanide of mercury, though very efficient
as an inhibitor, cannot be trusted as a germicide. ‘There are different ways
in which absorbent gauze such as this may be charged. One is to pass it folded
in about sixteen layers through a trough, such as the one before me, which
I have myself used, having a bar near the bottom to ensure the gauze being
kept well under the liquid. It is then, as soon as you please, squeezed to press
out superfluous liquid, and then, if wanted for immediate use, a simple way
is to place the masses of gauze—say, six-yard pieces—in a folded sheet, turn
the folded sheet over them, and roll it up. The folded sheet then absorbs the
still redundant liquid, and you have moist gauze ready for use in five minutes.
For the use of the ordinary surgeon it will probably be best to have the gauze
dried, on the understanding that it is again moistened with 1 to 4,000 sublimate
solution before being used. Here is a sample of the gauze in the dry state,
which, you see, does not give off dust even when freely handled.
Other articles may be charged as well as gauze with this substance. The
double cyanide being perfectly unirritating in its own substance, there is no
objection to having an excess of it. If you take, therefore, some of the pre-
paration and stir it up with 1 to 4,000 sublimate lotion, so as to produce an
opaque liquid, and put linen rags into it, and then place them in a folded towel
to take out the excess of liquid, you have your dressing ready prepared then
and there. It can thus be very easily worked on an emergency.
We have seen that the double cyanide requires about 3,000 parts of blood
serum to dissolve it. If, therefore, it is present in a gauze in the proportion
of about 3 per cent., you will easily understand that blood-serum may soak
through such a gauze time after time without washing the ingredient all out ;
so that it isa material which is admirably stored up in the dressing. That is
one of its three great advantages, the others being that, while trustworthy as
an antiseptic, it is completely unirritating. In actual practice the few layers
placed next to the wound are washed in a solution of carbolic acid I to 20 ;
this washes out the corrosive sublimate, which, though present in small amount,
might irritate the wound to some extent. The carbolic acid soon flies off, and
there is left in the application next the wound merely the unirritating double
cyanide, and under this we find that not only do wounds, the edges of which
are brought accurately together, unite beautifully by first intention, but even
eranulating sores heal by the gradual process of cicatrization from the edges—
heal by scabbing in a way that we have never seen so satisfactory under any
other dressing.
Having satisfied myself that this was really a useful material, | proceeded
to request a manufacturing chemist to provide it for me on a large scale. Messrs.
320 AN ADDRESS ON A NEW ANTISEPTIC DRESSING
Morson & Son, of Southampton Row, kindly undertook to do this, and I have
to thank them for the great pains they have taken in carrying out experiments
on this subject at my suggestion. Their manager, Mr. Taubman, soon informed
me that in his opinion there was exceedingly little mercury in this so-called
double cyanide of mercury and zinc. Very little mercury could be got from
it on testing in comparison with what would be obtained if it were a true double
salt. He asked if I was sure that the cyanide of zinc was not, after all, the
thing that was efficacious! Was the idea of the double cyanide altogether
a delusion? I need not say how much pleased I should have been if such had
been the case—if we could have had the cyanide of zinc without any poisonous
mercury in it as an antiseptic. The cyanide of zinc was a perfectly definite
compound, there could be no mistake about it. I proceeded to make experiments,
and I found, indeed, that cyanide of zinc had antiseptic properties. I made,
for instance, experiments of this kind: I took a piece of glass tube lke that
which I hold in my hand, and packed it in two inches of its length with a piece
of gauze charged with cyanide of zinc only, and then, holding it vertically,
poured serum of horse’s blood into it till the gauze was fully moistened ; and
then poured more in, till a quantity dropped out from the lower end equal to
that which had produced saturation, the upper part of the gauze being thus
thoroughly washed with the serum.
I then inoculated the top of the gauze with a potent septic drop. I had
another such tube packed with gauze that had no cyanide of zinc in it, and
I inoculated that in the same way after pouring serum upon it. I[ then put
each into a well-fitting stoppered bottle, so as to prevent any evaporation,
and placed them in the incubator. At the end of four days I opened the two
bottles. That which contained the gauze without the cyanide of zinc stank,
and, on taking portions of the gauze from either one end or the other, squeezing
them and examining under the microscope the fluid that escaped, there were
seen teeming multitudes of bacteria of various sorts. The bottle with the
cyanide-of-zinc gauze, on the other hand, had a pure odour of hydrocyanic
acid, which this gauze always has when moist. I then examined drops squeezed
from both ends, and I found no bacteria in the clear serum that was pressed
out, not only from the lower end, but even from the upper end, in the immediate
vicinity of the inoculating drop, and where the gauze had been drenched
repeatedly with the serum.
Now that, so far, is a result that no other antiseptic had ever given me.
Take iodide of mercury, for example. Comparatively insoluble as it is, if you
pour blood-serum upon it in such profusion you wash the iodide of mercury
out, and if you inoculate septically the part so washed you induce bacteric
AN ADDRESS ON A NEW ANTISEPTIC DRESSING 321
development. The test applied was, of course, an extremely severe one. In
actual surgical practice the discharge which pours into the dressing is pure to
begin with, supposing the wound to be aseptic at the outset. The septic agency
only acts from without where the dressing has not been washed by the discharge,
and in a far milder form than here, where a potent septic drop was used. Thus
we had clear evidence that the cyanide of zinc really is an antiseptic. On the
other hand, it turned out to be not so powerful antiseptically as our double
cyanide so called. In order to compare the two salts I made another experiment
similar to that last described. I packed three pieces of glass tube with gauze
in two inches of their length, one of the gauzes being charged with cyanide of
zinc and another with the so-called double cyanide (neither of these gauzes
having been treated with solution of bichloride of mercury), while the third
gauze was unprepared. Serum of horse’s blood was poured into the upper end
of each vertically held tube till it thoroughly soaked the mass of gauze, after
which each gauze was inoculated septically at the centre of its upper end. The
tubes were then placed vertically in stoppered bottles in the incubator. It
happened that in the septic liquid used for the inoculation that I used there
was, among other organisms, a species of streptococcus which had a remarkable
power of producing an acid fermentation in blood-serum. After four days
I proceeded to examine the contents of the three tubes. In the unprepared
gauze there was utter putrefaction. In the gauze prepared with cyanide of
zinc only, no putrefaction had taken place, but acid fermentation had occurred :
both at the upper and lower end of the gauze litmus paper was reddened on
application to the serum. In the putrid gauze turmeric paper was most
intensely reddened, much more so than by normal blood-serum, an alkaline
fermentation having occurred there. On the other hand, with the gauze that
contained the double cyanide, with mercury as well as zinc, both at the upper
and lower end the turmeric paper was reddened exactly as it was by the normal
blood-serum. This state of things continued the next day ; but on the following
day, six days after the commencement of the experiment, I found that at the
upper end, in the vicinity of the inoculated spot, this double-cyanide gauze
purpled litmus, while at the lower end it still reddened turmeric. At the end
of seven days the same condition persisted. After eight days, however, both
the upper and lower end of the gauze purpled litmus. This peculiar septic
organism, with the power of producing acid fermentation in serum, had gradually
worked its way, in spite even of the cyanide of zinc and mercury; but the
cyanide of zinc and mercury, you observe, had been much more efficacious
than the cyanide of zinc alone. The cyanide of zinc had prevented the
development of organisms that produced putrefaction, and only permitted the
322 AN ADDRESS ON A NEW ANTISEPTIC DRESSING
development of the coccus that produced acid fermentation. Cyanide of zinc
and mercury had for several days prevented all development. This was proof,
therefore, that the mercurial element in our compound was valuable, and that
we could not dispense with it.
It may be thought an unsatisfactory thing that there should have been
any organism able to work its way thus through a gauze charged with our
antiseptic. But I may remark, in the first place, that, as above stated, we
tested the material exceedingly severely ; in the second place, that it was a long
while before the organism penetrated the gauze even for a short distance ; and,
in the third place, that penetration of micro-organisms through such a dressing
into wounds does not seem to occur in practice, seeing that in the year during
which I have used this antiseptic in my surgical work at King’s College Hospital
we have had no single instance in which we have had any reason to suspect
septic change in the deeper parts of our dressing ; we have had no instance in
which deep-seated suppuration has occurred in an operation-wound made
through unbroken integument. If we have had any pus at all in such cases,
it has been from the surfaces exposed between stitches or at situations where
drainage-tubes have been inserted, where what I have termed antiseptic sup-
puration has occasionally shown itself, and even this in very slight degree.
Such being the case, I feel not only permitted, but bound to bring this material
under the notice of my professional brethren.
As to the composition of this so-called double salt, it is for the present
uncertain. This much is already established: that the cyanide of mercury is
in very much smaller proportion to the cyanide of zinc than Watts’s Dictionary
would lead us to expect from a true double salt. But what the precise com-
position of the salt is we do not yet know. I am having it investigated by the
Pharmaceutical Society, who have kindly undertaken the work.
There is another use for this material besides the charging of dressings.
The powder moistened with a weak solution of corrosive sublimate may be
rubbed into hairy parts, when it will convert the hairs into an antiseptic dressing.
Not long ago a medical friend of mine brought his wife to me with no less than
seven sebaceous cysts in the scalp, requesting me to remove them. Having
washed the hair with r to 20 carbolic-acid solution, I simply passed a comb
over each tumour in the line where I was about to transfix without shaving
at all; and, after taking out the cysts, rubbed in some of the moistened powder
into the hair in the vicinity. I then applied a dressing of cyanide gauze, and
I was glad to learn that all the seven wounds had healed without disturbance.
We have now in the hospital a case of psoas abscess, shown to be of spinal
origin, not only by the history of the case and the symptoms, but by the discharge
AN ADDRESS ON A NEW ANTISEPTIC DRESSING 323
of a portion of bone with the pus. That case is pursuing a course which, allow
me to say, psoas abscesses will pursue in the great majority of cases, if the
surgeon uses a trustworthy antiseptic, and takes the same pains with dressing
to the last as at the outset ; that is, he will find his trouble rewarded by the
complete cure of these formerly incurable cases. I say this because I grieve to
think that psoas and lumbar abscesses still seem to be regarded as hopeless
affairs by many surgeons. In this man’s case the temperature has never been
affected in the least; he has put on flesh rapidly; the discharge, after the
purulent and curdy matter that existed originally in the abscess was got rid
of, has been of a serous character, and is in small and diminishing quantity.
But the opening made for the discharge is in the vicinity of the pubes, and the
pubic hairs used, under such circumstances, to be a constant source of anxiety
to us unless frequently shaved away. Here we rub in at each dressing a little
of the moistened cyanide, and convert the hairs into an antiseptic application.
I will not at present enter into the details of the preparation of this material ;
these will be supplied in a note on a future occasion.
The sketch which I have given you of this investigation, though it has,
I fear, wearied you, conveys but a small idea of the toil it has involved. There
are those who still believe that the use of antiseptic substances in surgical
practice is always useless, if not injurious. The germ theory of septic diseases
is indeed now happily established incontrovertibly. All now admit that septic
mischief in our wounds depends upon the development of micro-organisms in
them derived from without. But the gentlemen to whom I refer are, more or
less logically, disposed to trust everything to the antiseptic powers of the human
tissues.
I believe I happened to be the first to direct attention to the antiseptic
agency of living structures, and there is, perhaps, no one who attaches greater
importance to it than I do. Without it, surgery in former days would have
been absolutely impossible. Still I know too well from experience that it cannot
always be trusted, and that the use of antiseptic adjuvants is in the highest
degree important ; and I have the satisfaction of knowing that there is among
you a constantly increasing number who, when they have operated on an un-
broken skin, with a fair field around for the application of their dressings, if
they see septic inflammation occurring in the wound with its attendant dangers,
know that it is their fault or the fault of the antiseptic appliances at their
disposal. To those among you who are impressed with this conviction I offer
the dressing which I have described as the most satisfactory that I have hitherto
met with; and I venture to hope that you will regard it as a not unwelcome
addition to your resources.
FURTHER OBSERVATIONS ON THE CYANIDE OF
ZINC AND MERCURY
Read before the Hunterian Society, November 27, 1889.
[Lancet, 1890, vol. i, p. 1.]
[ON the 27th of November, 1889, Sir Joseph Lister described to the Medical
Society the operations he had done on two cases of long-standing dislocation
of both shoulders, and in concluding made the following observations on the
double cyanide of zinc and mercury. |
Mr. President, I have hitherto felt considerable hesitation in publishing
cases in which the safety and success of an operation are essentially dependent
upon strict antiseptic management ; and my principal efforts for some years
past have been directed to an endeavour to procure, if possible, greater
simplicity and at the same time greater efficacy in our antiseptic methods. At
a recent meeting of the Medical Society’ I brought forward a kind of dressing
which I believe will prove more satisfactory than any which has been hitherto
employed. For the successful antiseptic treatment of a wound two essential
points are of course necessary. In the first place, we should proceed so as to
leave nothing septic in the wound before we apply the dressing, and in the
second place we should put on such a dressing as we can thoroughly trust to
keep out septic mischief until that dressing shall be changed. I had intended
to bring before you this evening some points with regard to the former of these
objects—the means by which the wound can be kept aseptic till the conclusion
of the operation; but since the communication that I made to the Medical
Society, I have been led to make further investigation into some matters
regarding the use of the materials I then described, which seem to me of sufficient
importance and interest to warrant me in taking this opportunity of bringing
them before you. The material, I may remind you, is a sort of double salt,
an amorphous powder, insoluble in water, composed of cyanide of mercury in
combination with cyanide of zinc. It does not seem to be a true double cyanide,
inasmuch as the proportion of the mercurial element is considerably less than
that which should be in a true double salt ; nevertheless, the mercurial element,
as I have found, is of essential importance to the full antiseptic efficacy of the
material. It was necessary that this powder, if introduced into a gauze or
other fabric, should be fixed so as to prevent it from dusting out ; for it is highly
* See Lancet, November 9, 1889 (page 309 of this volume).
OBSERVATIONS ON THE CYANIDE OF ZINC AND MERCURY 325
irritating to the nostrils, and besides, if it dusted out, the dressing charged with
it would lose more and more of its virtues. I described at the Medical Society
a means by which this was prevented; how by the use of starch the powder
might be fixed in any fabric which was charged with it. But I have long felt
that it would be an exceedingly desirable thing if this material could in some
way be coloured, because, being perfectly colourless, if a gauze is charged with
it, we have to trust entirely to the manufacturer as to whether the antiseptic
element is present in due proportion or is not. It would be very advantageous
if it could be coloured, so that we might see by the tint where the antiseptic
substance was, and whether it was uniformly distributed or otherwise. Therefore,
before publishing the note which I had promised as to the preparation of the
substance, [ made attempts to stain this material. I tried various forms of
dye, and I found that some of the aniline dyes are precipitated by this zinco-
mercuric cyanide and some are not. For instance, magenta is not precipitated
in the least, but methyl-aniline violet, and gentian violet, which seems to be
a mere variety of the same thing—these are precipitated, and an exceedingly
small amount of the dye is sufficient to give adequate colour to the double cyanide.
I proceeded to charge a piece of gauze with some of this dyed cyanide, to see
how it would tint it; and when it was dry I was much surprised to find that
the gauze charged with the tinted cyanide did not dust in anything like the
same degree as a gauze would have done which had received the untinted salt ;
so much so that a gauze charged with the tinted cyanide was very much on
a par as to dusting with the gauze charged by means of starch.
Of course, if this were so, it would be a very satisfactory arrangement ;
we should dispense with the starch and also with a quantity of sulphate of potash
which was used for purposes that I need not here refer to;! we should greatly
simplify the method of manufacture, and also, by getting rid of the starch, we
should make our gauze softer and more comfortable to the patient. It seems
a remarkable thing that the dye should thus be able to fix the powder. Of
course, we understand how the starch does it. The starch particles, becoming
attached to the particles of the cyanide, glue them, as it were, to the fibres of
the fabric. But how can we explain this dye, in the minute quantity in which
we use it, answering the same purpose? I have here some gentian violet dis-
solved in 50,000 parts of water, and you see the great colouring power that this
dye possesses. If I take a piece of gauze and dip it into the solution up to
a certain point, you will see the gauze coloured up to that point, but the part that
is moistened above by capillary attraction is colourless, showing the avidity
with which the fabric seizes the dye. The dye has a remarkable fondness for
' See p. 318 of this volume.
326 FURTHER OBSERVATIONS ON
the fabric ; at the same time, it is attached to the cyanide, for it is precipitated
by it. Wecan thus understand that the dye may act as a go-between, attaching
the cyanide to the fabric by virtue of its affinity for the fabric on the one hand and
for the particles of the cyanide on the other. The mode of attachment is altogether
different from that by starch, but the thing is done nevertheless. It seems to
me astonishing that the dye should have this power. The quantity of gentian
violet used is exceedingly small. We take, say, twenty grains of the salt, and
diffuse it in sixteen ounces of a liquid containing only 1-50,oo0th part of the
dye, draw a piece of the fabric through it, and so charge it with the requisite
amount of the cyanide. If now we consider what proportion the gentian violet
bears to the cyanide which it fixes, we find that there is only about one grain
of the dye to 140 grains of the salt. But more than that, the molecule, the
atom of the dye, is an exceedingly complex and heavy one ; so that if we consider
how many there are in comparison with the atoms of the cyanide which it fixes,
we find that there is only one molecule of the dye to nearly 600 molecules of
the cyanide salt. It is simply wonderful that each molecule of the dye should
have the power of fixing such a multitude of other molecules. It seems another
instance of what I have ventured to call solid solution. It is not a chemical
combination ; it is not a combination of one atom with one atom, but it is an
attachment of one molecule with a multitude of other molecules. I have often
contemplated with amazement the familiar fact of the solution of a soluble salt
in water. Put a bit of common salt into a tumbler of water, and, as everybody
knows, it will be quite uniformly distributed in a second or two. This marvellous
fact implies that every molecule of the chloride of sodium has an area of a mul-
titude of molecules of water in relation to it. If there were not the arrangement
of a definite number of molecules of water round every molecule of chloride of
sodium, there would not be an equable solution. So, I conceive, on the same
sort of principle, without chemical combination, this dye influences a multitude
of particles of cyanide in its vicinity. Here is a piece of gauze charged in the
way I have described, and you notice its delicate violet tint ; and we have the
satisfaction of knowing that, wherever we see the dye, there is the antiseptic
salt. You also observe that, when freely handled, it does not dust materially.
Thus we have the two advantages combined, one of which I had not hoped for—
that while we have the material dyed so as to show its presence by its tint, it
is also prevented from dusting.
Note.—After the above paper had been read, I was mortified to find that
some gauze charged by aid of gentian violet dusted to a very inconvenient degree.
This appeared to be due to the influence of the bichloride of mercury, which was
THE CYANIDE OF ZINC AND MERCURY 327
used in weak solution (1 part to 4,000) along with the gentian violet in the water
in which the cyanide salt was diffused. Bichloride of mercury interferes, to
a certain extent, with the precipitation of the gentian violet, and, leaving some
of the dye in solution, causes tinting of the gauze independently of the presence
of the cyanide salt, and at the same time it impairs the efficacy of the dye in
fixing the salt to the fabric. Yet the use of the bichloride of mercury is a matter
of great importance, for reasons which I have given elsewhere,’ and it became
necessary to look for some other dye on which the bichloride might not exert
this prejudicial influence. I have found that there are several colouring matters
which answer the purpose fairly well. Thus both carmine and prussian blue attach
the cyanide salt to a cotton fabric perfectly so long as it is moist, but when it is
thoroughly dry they are not very good as regards the question of dusting. The
dye which I have found to comply best with all the requisite conditions is logwood,
or rather the essential ingredient of logwood—haematoxylin, which is a definite
crystalline substance, and not unduly expensive.
The manner in which I have found it best to use this substance is the following.
It is incomparably better to apply it to the freshly precipitated and wet cyanide
than to mix it with the salt after its particles have been aggregated in the process
of drying. It may be well to mention here the manner in which the cyanide
is prepared. Cyanide of potassium, cyanide of mercury, and sulphate of zinc
are mixed together in solution in quantities proportioned to the atomic weights
of 2KCy, HgCy., and ZnSO,+7H.O; the cyanide of potassium and cyanide
of mercury being dissolved together in 14 oz. of water for every Ioo ers. of
potassium cyanide, and added to the sulphate of zinc dissolved in three times
that amount of water. The precipitate is collected on a strainer, and when
well drained is washed with two successive portions of water, equal in quantity
to that used for the solutions—viz. 6 oz. for every 100 grs. of potassium cyanide ;
at least this amount of washing being essential in order to free the precipitate
sufficiently from the highly irritating soluble salts which are associated with
it in its formation. The precipitate having been thus washed and drained, but
not dried, it is thoroughly diffused with pestle and mortar in distilled water
(6 oz. for every 100 grs. of potassium cyanide), containing in solution I part of
haematoxylin for every 100 parts of the cyanide salt, the amount of which is
known from the circumstance that the dry product of cyanide salt is almost
exactly equal in weight to the potassium cyanide employed. Haematoxylin
is readily soluble in a small quantity of hot water and remains in solution when
added to a large quantity of cold water. The cyanide salt, while it precipitates
the haematoxylin, changes its colour to a pale-bluish tint. This is advanta-
* Vide Lancet, loc. cit. (p. 309 of this volume).
328 OBSERVATIONS ON THE CYANIDE OF ZINC AND MERCUR™
geously enhanced by the addition of a little ammonia to the mixture, in the pro-
portion of r atom of ammonia (NH,=17) to each atom of haematoxylin (C.,H,,
O,3H.O = 356). More than this proves prejudicial. The ammonia is added
in a dilute form, and it is convenient to have the dilution such that one
fluid drachm of the ammoniacal liquid shall correspond to one grain of haema-
toxylin. The dye is further economized by allowing the ammoniated mixture to
stand for three or four hours and stirring it occasionally, so that the ingredients
may react thoroughly upon each other. If the mixture is filtered immediately,
there is considerable loss of colouring matter. The dyed salt having been drained
and dried at a moderate heat, is levigated, and may then be kept for any length
of time fit for use. When employed for charging a dressing, it is diffused by
means of pestle and mortar in solution of bichloride of mercury (1 to 4,000)
in sufficient abundance to drench the fabric thoroughly, for which 4 imperial
pints to 100 grs. of the salt will be found adequate. This will give a percentage
of between 2 and 3 of the cyanide to the dry gauze. For reasons which I have
stated elsewhere,’ the gauze should always be used moist ; and if it be prepared
for immediate use, as by the dispenser of a hospital, the process of drying may
be omitted, the gauze, after being hung up for a while to drain, being deprived
further of superfluous moisture by placing it for a while in a folded sheet. It
may afterwards be conveniently kept moist by wrapping it in a piece of
macintosh cloth. When obtained dry from the manufacturer, it should be
moistened again with the weak corrosive sublimate solution before it is used.
Vide Lancet, loc. cit. (p. 319 of this volume).
NOTE ON THE DOUBLE CYANIDE OF MERCURY
AND ZINC AS AN ANTISEPTIC DRESSING
Contributed by Lord Lister to Sir Hector Cameron’s Dr. James Watson Lectures, Glasgow, |!
[British Medical Journal, 1907, vol. i, p. 795. Together with a later Note. ]
I HAVE often regretted that the double cyanide of mercury and zinc is not
more generally employed, especially in foreign countries. This is, I feel sure,
due to want of acquaintance with it, and I avail myself of the opportunity
kindly afforded me by Sir Hector Cameron of saying a few words here regarding
its nature, mode of preparation, and use.
Professor Dunstan, of the Imperial Institute, who most kindly undertook to
investigate its composition, found it to be a double salt of very unusual type,
being a tetrazincic monomercuric decacyanide, Zn,Hg(CN),,.. Its insolubility
in water appears to be also a very unusual feature in a double salt.
Messrs. T. Morson and Son (of Elm Street, Gray’s Inn Road, London, W.C.),
to whom I am much indebted for the great pains they have taken in the prepara-
tion of the salt, have given me for publication the following formula :—
Pot. cyamid.96- per Cent. : «4. ws oe, % 46 parts.
Hydrarg. cyanid. a We a AT Sg 88,
Dissolve in water : ; : : : : PAQ- 55
Zine, silphat. AF 0a 1) ws Me oe, sen "DOZ . ,,
Dissolve in water : . : : > 220: |
When the solutions are cooled to about 60° Fahr., mix, collect the precipitate,
and wash until no precipitate occurs with ammon. sulphid.
The white powder so obtained is dyed with rosalane, + oz. being used to
colour 4 lb. of the powder.
I tried various aniline and other dyes, and found none that answered its
purpose in all respects so perfectly as purified rosalane (as supplied by Messrs.
Meister, Lucius, and Briining, of Hoechst-on-Main). Its principal object is to
attach the cyanide to a fabric charged with it, and this it does with absolute
security. At the same time the colour which it imparts to the white powder
has the important effect of indicating the presence and distribution of the salt
in the fabric.
LISTER II Z
330 NOTE ON THE DOUBLE CYANIDE OF MERCURY
Gauze may be charged by drawing it in several thicknesses through a 5 per
cent. solution of carbolic acid in which the dyed cyanide is diffused in sufficient
quantity to be about 3 per cent. of the weight of the dry gauze, the liquid being
constantly stirred to prevent deposition of the heavy salt.
Old rags or other absorbent fabrics can be readily charged by dipping several
layers of them in the 5 per cent. solution of phenol, and dusting one surface
with an excess of the powder, which is then diffused by folding the mass, and
pressing it till a pretty uniform tint is produced. The absolutely unirritating
character of the double cyanide makes a little excess of it in any parts a matter
of indifference.
The solution of carbolic acid is used because the cyanide powder is much
more readily diffused in it than it is in water, while it destroys any microbes
present in the gauze as it comes from the manufacturer. The solution of phenol
has the further advantage that it does not receive the slightest colour from the
dyed cyanide, so that the depth of tint of the fabric charged with it 1s in exact
proportion to the amount of salt it contains.
The gauze, as supplied by the chemist, is dry, and having lost the carbolic
acid used in charging it, may have been subsequently contaminated with septic
material. The double cyanide, though very remarkable for its inhibitory power
over bacteric development, is without efficacy as a germicide ; and the microbes
in the contaminating material would be free to develop in the deep parts of the
gauze as soon as the cyanide in them had been exhausted. In case of moderate
discharge this would probably never occur, thanks to the slight solubility of the
salt and its secure fixation by the dye. But in case of copious effusion of blood
and serum, the salt would in time be exhausted, and the microbes in the infective
material would be free to develop. In order to guard against this risk, the
dressing may either be damped throughout with the carbolic lotion, or, as ample
experience has proved to be sufficient, a portion of the gauze in several layers,
soaked with the lotion, may be applied over and around the wound and the rest
of the dressing used dry.
Bichloride of mercury must not be employed for moistening the gauze,
because it forms with the double cyanide a triple compound which is both
feebly germicidal and highly irritating.
The double cyanide might, I believe, be very satisfactorily used in military
practice as a first dressing, by dusting it over the wound with a pepper box, and
covering with any absorbent material that might be at hand. The salt might
be used with the utmost freedom, as experience has shown that there is no risk of
its producing poisonous effects. Some surgeons who undertook to use the cyanide
in this way in the late South African war, had unfortunately no opportunity
AND ZINC AS AN ANTISEPTIC DRESSING 331
of doing so at the front.1. But Mr. Cheatle informed me that granulating wounds
behaved more satisfactorily with the cyanide than with iodoform, while the
unpleasant odour of the latter was of course avoided. For further particulars
regarding the use of the double cyanide I would refer to an address on the anti-
septic treatment of wounds published in the British Medical Journal for the
28th of January, and the 11th and 18th of February, 1893.2, The part in the
number for the 18th of February contains the reference to the double cyanide.’
1 Since the above was published I have learned from Mr. Cheatle that he had considerable experience
with the use of the double cyanide as a first dressing on the battle-field in South Africa. Having found
that the prevailing strong winds made dusting with the powder impracticable, he used a paste made by
mixing the salt with a 1 to 20 solution of carbolic acid. This was readily improvised in his tent and was
taken to the field in a bottle. With it he smeared the surface of the wound and the surrounding skin,
and also his own fingers ; thus combining the germicidal action of carbolic acid with the inhibitory effect of
the cyanide. Cyanide gauze was then bandaged on. The cases were afterwards under the care of others ;
but he not unfrequently had the opportunity of seeing them again, and was well pleased with the results
obtained. See ‘A First Field Dressing’, by G. Lenthal Cheatle, British Medical Journal, September 8, 1900.
* This address is printed at p. 349 of this volume.
5 See p. 358 of this volume.
Z
to
AN ADDRESS ONY) THE PRESENT ‘POSITION TOE
ANIMSE EA IG SURGERY
Delivered before the International Medical Congress, Berlin, 18c¢o0.
[British Medical Journal, 1890, vol il, p. 377.]
Mr. PRESIDENT AND GENTLEMEN.—At the International Congress in London,
in 1881, Robert Koch demonstrated in King’s College his then new method of
cultivating microbes upon solid media. The illustrious veteran Pasteur was
present at the demonstration ; and at its conclusion exclaimed, ‘ C’est un grand
progrés, Monsieur.’ How vast have been the extensions of our knowledge which
have resulted from that great step in advance! Of these none perhaps have
been more striking than Koch’s own brilliant discovery of the cholera microbe—
picked out with unerring precision by his beautiful method from among the
multitude of bacteric forms that people the intestinal contents, and grown and
studied with as much definiteness as if it were a cabbage or a rose.
But while we have during the last nine years learned so much more of the
nature and habits of the micro-organisms which invade our bodies, a new and
surprising light has been thrown within the same period upon the means by
which the living animal defends itself against their assaults. This we owe to the
eminent naturalist Metchnikoff, who, having long carefully studied intracellular
digestion in the amoeboid cells which form the main mass of the bodies of sponges
and other humble organisms, was prepared to observe and rate at its true value
an analogous process in the wandering leucocytes of vertebrata. He found that
these migratory cells, with whose amoeboid movement we have been long familiar,
feed also like amoebae, and while almost omnivorous in their appetites, have
a special fondness for bacteria ; taking them into their protoplasmic substance
and digesting them, thus preventing their indefinite propagation among the
tissues. The cells which exercise this devouring function he termed phagocytes.
Various objections have been urged against Metchnikofi’s views ; but so
far as I am able to judge, he has met these effectively by his masterly series of
researches ; and his observations have been confirmed and extended by several
independent investigators.1_ For the sake of those among my audience who may
chance not to be familiar with Metchnikoff’s work, lam tempted to relate briefly
* See for example Dr. Tchistovitch, Annales de /’Institut Pasteur, 25 juillet, 1889, and Dr. Armand
Ruffer, British Medical Journal, May 24, 1890.
THE PRESENT POSITION OF ANTISEPTIC SURGERY 333
some of his experiments. The green frog, below the temperature of 20°C.
(68° Fahr.) is incapable of taking anthrax: the bacilli of that disease cannot grow
when introduced under the skin of that animal. To what was this immunity of
the frog to anthrax due? Were its juices an unfit pabulum for the microbe, or was
the phagocytic action of its leucocytes the explanation? In the hope of solving
this question, Metchnikoff formed a tiny bag out of the pith of the reed, and
having placed init some spores of anthrax, closed the bag and inserted it beneath
a frog’s skin. The pith wall of the bag allowed the animal’s lymph to penetrate
by diffusion, but excluded the leucocytes: and the result was that the spores
sprouted and grew into luxuriant threads of anthrax in the lymph, which was
thus proved to be a suitable medium for the growth of the bacillus. Meanwhile
under another part of the skin of the same frog had been placed a small piece
of the spleen of an animal that had just died of anthrax and contained the
microbe in its most virulent form; but there, the leucocytes having free access,
no growth occurred.
Another experiment on the same principle was still more instructive. It
consisted in introducing the spores of anthrax into the anterior chamber of the
eye of a frog, which, as we have seen, is naturally insusceptible of the disease ;
and also into that of a sheep and of a rabbit rendered insusceptible artificially
by “ vaccination’ with Pasteur’s attenuated virus. The aqueous humour of the
healthy eye contains few if any leucocytes to interfere with the perfect trans-
parency essential to vision. Accordingly, the spores sprouted and grew for a
while freely in the anterior chamber. Meanwhile, the growth of the bacillus
occasioned irritation to the eye, resulting in the immigration of a constantly
increasing number of leucocytes, producing turbidity and, in time, hypopion.
If a drop of the aqueous humour was withdrawn at an early period after the
commencement of the experiment, and examined with the microscope, it was
found to contain anthrax bacilli, some of them free in the liquid, but others
enclosed in the bodies of leucocytes. But a drop taken after a longer period
had elapsed showed no free bacilli, all being now within the leucocytes, and
exhibiting signs of degeneration in various degrees as the result of their ad-
vancing digestion. Finally the anthrax disappeared entirely and the eye
cleared up, the animal in all cases remaining healthy, although inoculation into
the aqueous humour proved a peculiarly deadly mode of infecting a susceptible
animal."
Here we see that the inflammation excited by the microbe becomes, through
the medium of the leucocytes, the cause of its destruction. How little can the
Jamented Cohnheim have dreamed that his observation of the emigration of
" See Annales de l’ Institut Pasteur, 25 juillet, 1887, pp. 326, 327.
334 AN ADDRESS ON
leucocytes in inflammation would prove to have so far-reaching a bearing upon
the pathology of infective diseases !
I have brought before you two samples of the kind of evidence upon which
the phagocyte theory rests, and if we accept it, as I believe we must, it serves at
once to explain much that has hitherto been mysterious in the relations of micro-
organisms to wounds. Take, for example, that which the surgeon makes for the
cure of hare-lip. Its posterior edge is perpetually bathed with the saliva, which
contains many kinds of septic bacteria. But these do not enter and people the
fibrine that glues together the cut surfaces, as they infallibly would do if those
surfaces were composed of glass or any other chemically inert material destitute
of life. It has long been very evident that the living tissues exerted a potent
influence in checking bacteric development in such a wound ; but what was the
nature of that influence? This used to be an enigma, but now receives its
natural explanation in the phagocytic action of the cells that crowd the lymph
soon after its effusion.
At the London Congress I brought forward an experiment which proved
that a blood-clot within the body may exert a powerful anti-bacteric agency.
I will not repeat the details of that experiment further than to say that a very
small piece of linen cloth soaked with putrid blood was mounted by means of
silver wire in the interior of a short glass tube open at both ends, which was
slipped into the jugular vein of a donkey, and kept in position between two liga-
tures. After two days the venous compartment was removed, and the coagulum
within it investigated. In and near the glass tube it was in a state of advanced
putrefaction, as was indicated by its foul odour and greatly altered appearance ;
and microscopic examination showed that 1t abounded with bacteria. But near
the wall of the vein it looked to the naked eye like a recent clot ; I could not detect
in it any putrid odour, nor could I discover bacteria with the microscope. Stained
sections of these outer parts of the coagulum, made after hardening in alcohol,
showed great multitudes of cells differing from one another in size and other
characters, just as is often the case with Metchnikoff’s phagocytes. I supposed
that these cells must have been in some way or other the anti-bacteric agents,
but how, I could not imagine. The phagocyte theory clears up the mystery.
By means of this same theory we can account for what would otherwise
have seemed to me incomprehensible—the use, without evil consequences, of
silk ligatures which have not been subjected to any antiseptic preparation. We
learn from the experiments of Ziegler and others that leucocytes soon penetrate
very thin spaces between plates of glass or other chemically inert foreign bodies
inserted among the tissues. And we can understand that they may creep into
* See Transactions of the London International Medical Congress (p. 275 of this volume).
THE PRESENT POSITION OF ANTISEPTIC SURGERY 335
the intervals between the fibres of a silk thread and destroy any microbes that
may have lodged there before they have had time to develop serious septic
mischief. But there must surely be a limit to the thickness of the threads. No
one, I imagine, would feel justified in leaving in the peritoneal cavity an unsteril-
ized cord as thick as a finger. Dr. Bantock, whose remarkable series of successful
ovariotomies may seem to justify his practice, does not, I believe, prepare his
ligatures antiseptically ; and I understand that he uses, for tying the pedicle
of a tumour, silk twist of so strong a nature that it can be trusted to bear the
needful strain, with a diameter of only about 1-30th of an inch. But it would
surely be wiser to sterilize even so slender a cord. Who can say that septic
mischief may not occasionally lurk in the ligature in a form which may baffle
the phagocytes ?
The success in abdominal surgery achieved by Bantock and Lawson Tait,
without, it is said, the use of antiseptic means, proves a stumbling-block to some
minds. But in truth the practice of these surgeons is by no means conducted
without antiseptic precautions, nor would they, I am persuaded, desire that
such an impression should prevail. Both are scrupulously careful in the purifi-
cation of their sponges, and if there is one thing more important than another in
the antiseptic management of wounds of the peritoneum it is the avoidance of
impure sponges. Both observe the strictest cleanliness—which is surely an
antiseptic precaution—for it. owes its virtue to the fact that it presents the
septic organisms in the smallest possible numbers and thus reduces their power
for evil to the utmost that can be done by any measures that are not germicidal.
Both these surgeons also wash out the peritoneum with water so as to get rid
of coagula without injuring the peritoneal surface by rubbing it with sponges,
and this is done in order to avoid the risk of sepsis in residual clots. The drainage
of the peritoneum is another antiseptic measure, and Dr. Bantock, I am informed,
has the sponges which absorb the serum wrung out of sulphurous acid, and
changes them very frequently.
This is a department of surgery in which I have had but little personal
experience. But I can see that while the measures to which I have referred are,
so far as they go, highly valuable, it must be in itself a very desirable thing to
avoid the direct application to the peritoneum of strong and irritating antiseptic
solutions. But now that we are all agreed that microbes are the evil with which
we have to contend, it is surely wiser to ensure by germicidal means their entire
absence from our hands and instruments rather than trust to the most pertect
cleanliness in the ordinary sense of the term. And if water is used for washing
out the peritoneum, prudence seems to me to dictate that it ought to be freed
entirely from living organisms, if this can be done without making it irritating,
336 AN ADDRESS ON
This object is, I believe, aimed at by Dr. Bantock by boiling the water before
using it, but I would advise as more effectual an extremely weak solution of
corrosive sublimate, such as I in 10,000, which, as Koch has taught us, may be
implicitly trusted as antiseptic, while it is not appreciably irritating and involves
no risk of mercurial poisoning.
In general surgery, the direct application of strong antiseptic solutions
is not attended with the same disadvantages as in operations in the peritoneal
cavity. My practice for some time past has been to wash the wound, after
securing the bleeding-points, with a pretty strong solution of corrosive sublimate
(1 to 500) and irrigate with a weaker solution (1 to 4,000) during the stitching,
and I have had no reason to complain of the results. To this, however, I must
make one marked exception. When applied to the healthy synovial membrane
of a joint, the 1 to 500 sublimate lotion produces inconvenient irritation, and
therefore, when opening an articulation—as for suturing a transverse fracture
of the patella—-I abstain from the washing, and, as a substitute, have hitherto
irrigated during the whole operation with the weak solution (1 to 4,000).
And yet I must confess that I have for a long time doubted whether either
the washing or the irrigation was really necessary. These doubts have been
raised partly by experiments—some of which I mentioned at the London
Congress—which had proved to me that normal blood and serum, and even
pus, were by no means favourable soils for the growth of microbes in the form
in which they are present in the air—and partly by reflection upon the experience
we had when we used the carbolic spray.
As regards the spray, I feel ashamed that I should have ever recommended
it for the purpose of destroying the microbes of the air. If we watch the formation
of the spray and observe how its narrow initial cone expands as it advances,
with fresh portions of air continually drawn into its vortex, we see that many
of the microbes in it, having only just come under its influence, cannot possibly
have been deprived of their vitality. Yet there was a time when I assumed
that such was the case, and, trusting the spray implicitly as an atmosphere free
from living organisms, omitted various precautions which I had before supposed
to be essential. Thus, in opening the pleura in empyema for the purpose of
evacuating the pus and introducing a drainage-tube and afterwards in changing
the dressings, I had previously applied over the opening a piece of cloth steeped
in an antiseptic lotion to act as a valve and prevent the entrance of air during
inspiration. But under the spray I omitted the valve and allowed the air to
pass freely in and out of the pleural cavity, although I used the spray at such
a distance from the producing apparatus that it was dry and transparent, with
the particles of carbolic solution necessarily widely separated from each other.
THE PRESENT POSITION OF ANTISEPTIC SURGERY 337
And these particles cannot have been in more than instantaneous contact with
much of the dust before it was drawn within the chest, and securely protected
by the pus or serum there from any further action of the antiseptic. It is
physically impossible that the microbes in such dust can have been in any way
whatever affected by their momentary presence in the spray.
Yet we did not find our results in the treatment of empyema rendered worse
by this false confidence in the spray. There are few more beautiful things in
antiseptic surgery, as contrasted with the results of former practice, than to
see the abundant purulent contents of the pleural cavity give place at once
to a serous effusion, rapidly diminishing from day to day till, the opening being
allowed to close, the pleura, restored to its healthy condition, resumes its normal
function of absorbing gases; and, as the natural vacuum within it becomes
re-established, the atmospheric pressure blows up the contracted lung, and
brings it again into contact with the chest wall unimpaired in its dimensions.
Such a case we had witnessed before the days of the spray, and such we continued
to see during its use.
If, then, no harm resulted from the admission day after day of abundant
atmospheric organisms to mingle unaltered with the serum in the pleural cavity,
it seems to follow logically that the floating particles of the air may be disregarded
in our surgical work; and, if so, we may dispense with antiseptic washing
and irrigation, provided always that we can trust ourselves and our assistants
to avoid the introduction into the wound of septic defilement from other than
atmospheric sources.
Since we abandoned the spray, three years ago, we have been careful to
compensate for its absence, not only by antiseptic washing and irrigation, but
,by surrounding the seat of operation with widespread towels wrung out of an
antiseptic solution. For the spray, though useless for the object for which
it was originally designed, had its value as a diffuse and perpetual irrigator,
maintaining purity of the surgeon’s hands and their vicinity as an unconscious
caretaker. But if besides the spray we give up all washing and irrigation of
the wound, our vigilance must be redoubled. Yet I believe that, with assistants
duly impressed with the importance of their duties, the task would prove by
no means difficult.
I have not yet ventured to make the experiment on any large scale, although
I have long had it in contemplation. It is a serious thing to experiment upon
the lives of our fellow men, but I believe the time has now arrived when it may
be tried. And if it should succeed, then perhaps may be fulfilled my early
dream. Judging from the analogy of subcutaneous injuries, I hoped that
a wound made under antiseptic precautions might be forthwith closed com-
338 AN ADDRESS, OWN
pletely, with the line of union perhaps sealed hermetically with some antiseptic
varnish, and bitter was my disappointment at finding that the carbolic acid
used as our antiseptic agent induced by its irritation such a copious effusion of
bloody serum as to necessitate an opening for its exit ; hence came the drainage
of wounds. But if we can discard the application of an antiseptic to the cut
surfaces, using sponges wrung out of a liquid that is aseptic but unirritating,
such as the I to 10,000 solution of corrosive sublimate, we may fairly hope that
the original ideal may be more or less nearly attained.
We have already made of late considerable approaches towards it. Our
wounds being no longer subjected to the constant irrigation of the spray, and
carbolic acid having given place to the less irritating, though more efficient,
solutions of corrosive sublimate, serous discharge is much less than formerly,
and less drainage is required. In many small wounds where we used to find
drainage imperative we omit it altogether, and in those of larger extent we
have greatly reduced it. Thus, after removing the mamma and clearing out
the axilla, I now use one short tube of very moderate calibre, where I used to
employ four of various dimensions. But it would be a grand thing if we could
dispense with drainage altogether; without applying the very firm elastic
compression adopted by some surgeons, which, besides involving the risk of
sloughing of parts of low vital power, with the chance that it may after all fail
in its object, proves often extremely irksome to the patient.
It remains for me to say a few words regarding the best form of external
dressing. Some surgeons have thought that simplicity and efficiency may be
combined in the maximum degree by the use of cotton-wool sterilized by heat.
But though it may be a simple thing to heat the wool appropriately by means
of suitable apparatus in a public institution, for the ordinary practitioner 1t would
be impracticable. And as regards efficiency, I need hardly remark that cotton-
wool, merely aseptic, can only exclude septic mischief when it is in the dry state.
When it is soaked to its external surface with a copious discharge, it must be
liable to become septic en masse. And however well we may succeed in the future
in diminishing or abolishing discharge from wounds made by the surgeon, there
must always remain cases in which it will occur in greater or less amount.
Contused wounds, for example, into which dirty material of one kind or
another has been introduced before they are seen by the surgeon, must be purified
by the use of powerful antiseptic means, and must, for a while, discharge freely.
The same is to be said of cases in which we make the attempt, often with signal
success, to restore an aseptic condition in a part affected with septic sinuses.
Again, there are abscesses in which, in the present state of our knowledge, we
cannot avoid the occurrence of considerable serous oozing, and in which a
THE PRESENT POSITION OF ANTISEPTIC SURGERY 339
perfectly trustworthy antiseptic dressing is a matter of life and death. And
whenever discharge is considerable, it is essential that the dressing be of a kind
which will not permit the development of septic organisms in it, although it
be saturated throughout ; and this can, I believe, only be attained by the use
of chemical antiseptic substances.
I have for some time past employed for this purpose a combination of the
two cyanides of zinc and mercury, which appears to fulfil the requisite conditions
of antiseptic efficacy and due storage of the agent in spite of free discharge,
together with absence of irritating properties. Having already published on
this subject, I will not detain the members of the Congress with details regarding
it, further than to say that since the date of that publication Professor Dunstan,
of the London Pharmaceutical Society, has devised means by which the substance
can be prepared in a perfectly definite manner, and containing twice as great
a percentage of the cyanide of mercury as that which we have hitherto used ;
and, as I have ascertained that the cyanide of mercury is the more important
ingredient antiseptically, and also that its larger amount in Dunstan’s material
does not make the salt irritating, we may fairly regard the new preparation as
an improvement. And yet we have had no need to complain of this substance
in the form in which we have used it hitherto. Those who have followed my
practice at King’s College Hospital during the year and a half in which this
dressing has been employed will agree with me that we have secured a constancy
of aseptic results which has more than ever justified the performance of operations
once quite unwarrantable.
In thus referring to my own work, I do so, believe me, in no boastful spirit ;
but in the hope of stimulating some of those whom I address on this memorable
occasion to more thorough earnestness in pursuit of the great objects of anti-
septic surgery.
ON THE PRINCIPVES OF AN TISEP TIG SURG mh Rad
[Virchow-Festschrift. Bd. iii (1891). ]
THE fundamental truth on which Antiseptic Treatment in surgery is based
is now universally recognised. All are now agreed that the once formidable
complications of wounds are caused by living organisms derived from the external
world and incapable of originating de novo within the animal body. But the
practice which has resulted from a recognition of this truth varies greatly in
the hands of different surgeons ; and it is of great importance to endeavour to
ascertain, in accordance with the present state of our knowledge, what are the
points which it is essential to attend to, so that on the one hand we may be freed
from the encumbrance of needless precautions, and on the other hand may not
omit anything which is conducive to such constancy of aseptic results as can
alone justify many operations which are in themselves desirable but fraught
with grave dangers if septic complications arise.
The original idea of the antiseptic system of treatment was the exclusion
of all microbes from wounds. It had long been obvious that the putrefaction
which at that period attended all wounds except the very small proportion which
united entirely by the first intention, was a grievous cause of mischief. Various
antiseptic substances were used to mitigate the evil, but entirely to prevent
its occurrence appeared hopeless so long as it was believed, in accordance with
the teaching of Gay Lussac, backed by the high authority of Liebig, that the
access of a minute quantity of free oxygen could start progressive fermentative
changes in organic substances. Where discharge escaped from a wound, oxygen
must be able to enter. But when Pasteur had shown that putrefaction and
other fermentative changes were caused by the growth of micro-organisms, and
had at the same time demolished the idea of spontaneous generation, the problem
of the prevention of putrefaction in wounds seemed no longer hopeless. The
fermentative microbes could not arise de novo in the blood or tissues, and the
experience of the absence of all danger in simple fracture seemed to indicate
that they could not gain access by any other channel than an open wound.
It therefore seemed possible that putrefaction might be entirely prevented in
wounds by treating them with some substance which might destroy the life
of the microbes, though not excluding the atmospheric gases.
The first attempt to put this idea in practice was made with compound
fractures, in which the evils caused by putrefaction were especially manifest
ON THE PRINCIPLES OF ANTISEPTIC SURGERY 341
J
and disastrous; and the substance which I employed for the purpose was.
undiluted carbolic acid, a most potent germicide. The experiment answered
my most sanguine expectations ; the compound fractures following the same
safe and tranquil course as simple ones.
The powerful caustic property of the agent employed was of trivial moment
in comparison with the greatness of the danger to be averted in compound
fracture, but made it quite unfit for application to incised wounds. But we soon
found that carbolic acid could be used with equally good effect under various
forms of dilution, so that the application of the principle could be extended to
wounds in general. The result was a complete revolution in the practice of
surgery. Hospitals which had previously been little short of pest-houses
became more healthy than private dwellings had been before ; and operations
which had been from time immemorial prohibited on account of their danger
were freely and successfully performed.
Meanwhile it soon became apparent that putrefaction was by no means
the only evil that was avoided by treatment conducted on these lines. Hospital
gangrene, though in itself entirely free from unpleasant smell, disappeared as
if by magic, and the same was the case with erysipelas and odourless forms of
suppuration. This naturally suggested the idea that various diseases to which
wounds were liable, though not septic in the original sense of the word, were,
like putrefaction, caused by microbes, each disorder having, probably, its own
specific organism ; a view the truth of which has been amply demonstrated by
the study of bacteriology, to which the success of antiseptic treatment in surgery
gave a powerful impetus.
Thus the attempt to exclude microbes entirely from wounds was followed
by results which more than fulfilled the highest hopes entertained of it. Yet the
advance of knowledge has shown that to carry out such an idea in its entirety
is on the one hand impossible, and on the other hand unnecessary.
It has been ascertained that many common bacteric forms produce spores
which resist for a long time the germicidal power of all known agents which could
be used in operations. Hence to exclude living microbes entirely from wounds
is an impossibility.
It is, on the other hand, happily unnecessary; and that for more reasons than
one. In the first place, it appears that none of the bacteria which can cause
mischief in wounds are of the spore-bearing kinds,’ while the sporeless bacteria,
such as the various streptococci and staphylococci and the Bacillus pyocyaneus,
+ An exception was once met with by von Volkmann who observed anthrax result from the use cf
the catgut ligature, prepared, no doubt, from the intestine of a sheep that had died of that disease. But
this risk having been pointed out, care is now taken to treat the catgut in such a way as to make such
an occurrence impossible.
342 ON THE PRINCIPLES: OF ANTISEPTIC SURGERY
have been shown by the most careful recent investigations to be deprived of
life within a minute by a I to 20 watery solution of carbolic acid,’ the agent
which we have always trusted for the purification of sponges and instruments,
the hands of the operator, and the integument of the patient at the seat
of operation.
These are the points of greatest importance to attend to during the per-
formance of an operation, the once dreaded atmospheric dust being, as it would
seem, a matter that may be disregarded. We learn from various independent
inquiries that the effects of micro-organisms upon the living body are greatly
influenced by the dose, that is to say by the numbers in which they are present
at the point of introduction.” And this seems to provide a clue to under-
standing how bacteria in the attenuated and minutely subdivided form in which
they are present in the atmosphere may be effectually disposed of by the natural
antiseptic action of the blood and the tissues. In pre-antiseptic days this natural
antisepsis often triumphed over enormous obstacles, preventing the layer of
lymph and coagulum between cut surfaces from putrefying, in spite of the use
of unclean sponges, instruments, and hands, and the presence, over the outlet
of the wound, of water dressing which, though cleanly when applied, was within
a few hours a stinking, putrid mass. But under the converse conditions in which
we now operate, this beneficent natural agency may, it seems, be implicly
trusted, if the microbes which enter the wound are only such as are deposited
from the atmosphere. That such is really the case has become apparent from
the uniform attainment of aseptic results by the use of means which could not,
as we now see, completely exclude living atmospheric organisms, whether spore-
producing or otherwise, during the performance of operations. The carbolic
spray, which was introduced for the purpose of destroying the microbes of the
air, could not, from its physical constitution, really effect that object,? and owed
whatever good it did to its properties as an irrigator. But no system of irrigation
that can be devised can prevent, during the application of the sutures, the
occasional entrance of air into deep parts of the wound from which blood is
oozing on which the liquid of irrigation cannot act Yet under the use of the
spray or other forms of irrigation the results obtained may be fairly described
as uniformly aseptic, when opportunity for efficient antiseptic work was afforded
by unbroken skin of sufficient extent for the needful dressings. The complete
exclusion of living atmospheric organisms during operations is impossible ;
but no harm appears to arise from their introduction.
* Vide Behring, ‘ Ueber Desinfection,’ &c., Zeitschrift fiir Hygiene, Neunter Band, 1890, p. 417.
* Vide W. Watson Cheyne, Suppuration and Septic Diseases, Pentland, Edinburgh, 1889, pp. 73 ff.
* Vide Transactions of the Tenth International Medical Congress, vol. i, p. 32 (p. 336 of this volume).
ON. THE PRINCIPLES OF ANTISEPTIC SURGERY 343
Confirmation of this opinion has lately come from an unexpected quarter.
The glowing accounts published by Koch ten years ago! of the antiseptic pro-
perties of corrosive sublimate, led us to adopt solutions of that substance in
place of the 1 to 40 carbolic lotion for washing and irrigating our wounds. But,
beautifully conclusive as Koch’s experiments appeared, it turns out that the
effects of the bichloride supposed to be due to germicidal action were in reality
caused by the inhibitory power which, as was shown by Koch, that agent possesses
even when present in extremely minute proportions ; and that if, instead of being
merely washed away, however carefully, from the objects on which it has
been made to act, it is got rid of entirely by converting it into inert sulphide,
the original reports have to be toned down to an extraordinary degree. Instead
of the resisting spores of anthrax being killed, as we were at first led to believe,
by being dissolved in 20,000 parts of bouillon acting for ten minutes, we now
learn that a solution of twenty times that strength fails to deprive them of
vitality by an action of some hours’ duration.” And even some sporeless micro-
cocci resist the germicidal action of the bichloride in a most unexpected manner.
Thus Behring found that the Staphylococcus pyogenes aureus was not destroyed
completely by a r to 1,000 solution of sublimate in bouillon acting for twenty-tive
minutes at about the ordinary temperature of wounds, 22° C.2 Such being the
case, we cannot suppose that corrosive sublimate as I have used it can have
acted with germicidal effect upon that microbe. My practice has been to abstain
from irrigation during the operation, and at its conclusion wash the wound
with r to 500 solution and irrigate during the application of the sutures with
a I to 4,000 lotion. As regards the washing, considering its very brief duration
and also that the germicidal action of sublimate is greatly interfered with by
albuminoid substances, such as the coagula in which the microbes are entangled,
I cannot conceive that the process can have acted destructively on any of the
Staphylococcus pyogenes aureus which might have been deposited on the wound
from the atmosphere. And as to the irrigation, it was obviously simply nuga-
tory with respect to that species of microbe.
Nevertheless entire success attended this use of the sublimate; and we are
therefore forced to conclude either that the Staphylococcus pyogenes aureus,
which seems to be the most frequent cause of suppuration in man, never fell
upon our wounds during the space of about seven years from the air of our
operating theatre, or else that, although present, unharmed by our sublimate
lotions, it failed to develop. It has, indeed, been shown by experimental
' Vide ‘ Ueber Desinfection’ by Dr. Robert Koch, Mitthetlungen des Kaiserlichen Gesundheitsamies,
Band I, Berlin, 1881.
* Vide Behring, op. cit., pp. 441, 443.
* Vide Behring, op. cit., p. 404.
344 ON THE PRINCIPVES OFtANIISEP DIC SURGERM
research ! that the pyogenic organisms are by no means abundant constituents
of the dust of hospitals; but their rarity can hardly explain the entire absence
of suppuration in our wounds for so long a period, and the fact can, I think,
only be explained by the co-operation of the natural antisepsis.
It would, however, be a mistake to suppose that no good can ever be done
by corrosive sublimate used in the manner which I have described. Resisting
as the staphylococci have shown themselves to that agent, there are other
microbes very mischievous to wounds, such as the Streptococcus pyogenes, the
streptococcus of erysipelas and the sporeless Bacillus pyocyaneus, which are
destroyed by very much weaker solutions.?, And it may be well that if, as once
occurred in my experience, a careless nurse were to come fresh from fomenting
a bad case of erysipelas and, without changing her dress, to hand sponges at
an operation, the washing with r to 500 sublimate lotion might avert a calamitous
attack of that disease.
But if, for the sake of guarding against carelessness on the part of our assis-
tants we think it prudent to wash our wounds before stitching them, it will,
I believe, be wise for us, in the present state of our knowledge, to revert to that
which we trusted in former years, the I to 40 solution of carbolic acid. This
agent has been shown to be far more uniform in its action upon micrococci than
corrosive sublimate. Behring found that even the staphylococci are killed in a
minute by a solution of about the strength mentioned,’? while, at the same
time carbolic acid is not hindered in its action by albuminoid substances in at
all the same degree as sublimate is. The r to 40 solution, while it appears
adequate for the purpose, is far less irritating than the I to 20 lotion, and there-
fore induces less discharge and involves less necessity for drainage. But here,
as in other cases, prevention is better than cure ; and it must ever be borne in
mind that nothing that the surgeon can do can make up for want of care in his
assistants. If, forexample, a pair of forceps is handed to the operator with the
intervals between its teeth occupied by dry septic pus, and a portion of this
dirt becomes detached and left in the wound, the evil cannot be corrected by
any antiseptic wash that is now at our disposal or any that the world is likely
ever to see. Hence I must repeat that our chief attention must be devoted to
enforcing scrupulous care on the part of all concerned in the operation in
guarding against the grosser forms of septic impurity. Towels dipped in an
+ Vide ‘Cheyne, op." cits, 1p. /86-
* My colleague Professor Crookshank has ascertained that a cultivation of the streptococcus of
erysipelas in bouillon is killed by a solution of sublimate in 4,000 parts of water acting for one
minute.
* Vide Behring, op. cit., p. 417. Crookshank finds that Staphylococcus pyogenes aureus is killed in
one minute by 1 to 50 watery solution of carbolic acid.
ON THE PRINCIPLES OF ANTISEPTIC SURGERY 345
antiseptic lotion and spread widely round the field of operation are an important
aid in this respect.
The foregoing considerations indicate that the troublesome complication of
irrigating during stitching may be safely omitted.
The operation being concluded, an external dressing such as shall effectually
prevent the access of septic mischief till healing is accomplished is, of course,
a matter of essential importance. For this purpose some surgeons have of late
years employed materials merely aseptic, such as cotton wadding sterilized by
heat. But such a dressing having nothing in it to counteract any accidental
defilement, must demand an almost impossible degree of care in its manipulation
in order to ensure that it is truly aseptic as left upon the patient. The mere
aseptic dressing has also the fatal defect that it is hable to be occasionally soaked
to the surface with discharge, in which septic development will then be free
to spread inwards to the wound. I believe, therefore, that a dressing, in order
to be trustworthy, must be charged with some chemical antiseptic substance.
Ideally this substance ought to possess three qualifications; it should be
thoroughly reliable in its antiseptic action, it should be capable of being stored
up in the material charged with it so that it cannot be washed away by the dis-
charge before the dressing is renewed, and it should be free from irritating proper-
ties, so as not to interfere with healing. The nearest approach to this ideal which
I have yet met with is presented by a combination of cyanide of mercury with
cyanide of zinc. Chemists are not agreed as to whether the two constituents
are united in true chemical combination. But however this may be, their
association is so intimate that, whereas the cyanide of mercury alone is freely
soluble in water and serum and highly irritating to the skin, the combination
‘is almost absolutely insoluble in water and requires about 3,000 parts of serum
to dissolve it at the temperature of the human body. Hence, if diffused in
a dressing, it remains most efficiently stored in spite of very free discharge ; while
it is so slightly irritating as not to interfere materially with healing, requiring
no protective layer to be interposed between it and the wound. As regards
its antiseptic virtues, it is very remarkable for inhibitory efficacy, i.e. for the
power of preventing the development of microbes in its vicinity, even in the
liquid which tests more severely than any other the antiseptic properties of
mercurial compounds, viz. the mixture of serum and blood corpuscles which
constitutes the first and most copious discharge from a wound. It is, how-
ever, very feeble as a germicide: and in order to make sure that a dressing
containing it shall have no hurtful organism alive in it when it is applied,
it is well to damp the dressing with a germicidal lotion before applying it.
For this purpose a I to 20 carbolic solution seems the best that can be em-
LISTER II Aa
346 ON THE PRINCIPLES OF ANTISEPTIC SURGERY
ployed.’ The carbolic acid soon flies off and leaves nothing in contact with the
wound but the unirritating cyanide and the fabric charged with it.
In changing the dressing, the skin around the wound is purified on each
occasion with carbolic lotion, the wound itself having been previously covered
with some trustworthy antiseptic material to avoid the chance of its contamina-
tion. These may seem minute details to refer to here; but in truth they all
illustrate principle.
In wounds already septic, attempts are made with more or less success to
restore the aseptic state; but this is a matter on which it is not now needful
tO Enter:
Abscesses, whether acute or chronic, are a field for antiseptic surgery which
yields very beautiful results, in striking contrast with those of former practice
and at the same time of great pathological interest.
As an example of the former class let us take a case of extensive suppuration
of the mammary gland during lactation. Here, under the old system of poul-
ticing, protracted suppuration followed the evacuation of the cavity ; and in
spite of free incision, sinuses often remained which could only be cured by laying
them open throughout their extent. Under antiseptic management, the abscess
being emptied by a puncture sufficient to admit the introduction of a drainage-
tube, nothing but bloody serum is found next day upon the dressing, the serous
discharge diminishes rapidly, and healing is complete in a very few days, sinus
of the mamma being a thing unknown.
To illustrate the chronic class may be taken a psoas abscess consequent
on tubercular caries of the spine. Under free incision and poulticing, such cases
were almost invariably fatal. If the patient survived the acute fever of the first
few days, he perished after a longer or shorter period of hectic caused by protracted
free suppuration. But if under antiseptic precautions a drainage-tube is inserted
and, without the introduction of any medication into the abscess, a trustworthy
dressing is applied, no fever whatever occurs, and the discharge, as in the acute
case, is as a rule sero-sanguineous at the outset and afterwards merely serous
and soon trifling in amount; and if scrupulous antiseptic care is maintained
a cure is almost always at last effected.”
* A solution of bichloride of mercury is of little value for this object, inasmuch as it forms with the
two cyanides a soluble salt of very feeble germicidal power.
* Acting on a hint derived from the Vienna practice of washing out these abscesses with a weak anti-
septic lotion and then introducing iodoform and closing the incision, I have of late years washed the
cavity with 1 to 10,000 solution of corrosive sublimate and stitched the wound; dispensing with the
iodoform which, I believe, cannot effect what has been expected of it, while it involves a certain risk of
iodoform poisoning. The results have been much on a par with those of the Vienna practice. Quite
recently, however, we have derived very great advantage from adopting the use of the ‘ flushing gouge’
suggested by Mr. Arthur Barker, by which the pyogenic membrane and all cheesy matter, with sequestra,
OM Lat, PRINCIPLES ‘OF ANTISEPTIC SURGERY 347
When first I witnessed the remarkable fact of the entire cessation of sup-
puration as a result of relieving abscesses of their contents and at the same time
preventing the access of micro-organisms from without, I inferred that microbes
could have nothing to do with the production of the pus, but that it was caused
by inflammation which, however it had originated, was kept up by the tension
of the pent-up liquid operating through the nervous system. This view has,
however, been disproved for both acute and chronic abscesses ; for the acute by
Ogston’s observation that they invariably contain micrococci, which experiment
has since proved to be truly pyogenic, and for the chronic by Koch’s discovery
of the tubercle bacillus, which we now know to abound in the pyogenic mem-
brane and caseous material in such cases. Some other explanation is therefore
called for. As regards acute abscesses, if we consider what is the primary
difference made by a poultice, as compared with an antiseptic dressing, we see
that putrefaction is admitted by the former, while it is excluded by the
latter. And I conceive that the acrid products of putrefaction act injuriously
upon the pyogenic membrane and prevent destruction of the micrococci by
the natural antisepsis which is always disposed to operate, but, so long as the
abscess is unopened, is hindered by the disturbing influence of tension caused
by the rapidly accumulating pus.
In chronic abscesses the slowly increasing contents cause but little tension
But we know that a very slight degree of tension on the wall of a cavity con-
taining fluid is sufficient to keep up chronic inflammation in the sac and
surrounding tissues. This is well illustrated by the obstinacy of chronic bursitis
patellae so long as the bland serous contents remain in the sac ; and conversely
the rapid cure that takes place when provision is made antiseptically for the
escape of the fluid. Not only does the tendency to abnormal effusion of fluid
cease, but the inflammatory induration around the sac speedily disappears.
And as inflammation, in whatever degree, is always a cause of weakness of the
part affected by it, we can understand that, so long as a psoas abscess remains
unopened, the enfeeblement of the surrounding tissues, caused in the way referred
to, may place the tubercular vertebrae at a disadvantage in their combat with
the tubercle bacilli and prevent them from throwing off the disease as they would
have done before abscess had occurred, if the spine had been placed at rest in
the recumbent posture. If tension is relieved by antiseptic drainage, the tissues
are allowed to recover vigour and assert their supremacy. But if such an abscess
is poulticed after incision, though tension is removed, far worse causes of dis-
turbance come into operation. The pyogenic organisms, previously absent,
are simultaneously scraped away and washed out. An antiseptic dressing is of course applied to the
sutured wound, which may either heal at once throughout or furnish a temporary leakage of serum.
Aaz
348 ON THE PRINCIPLES OF AN TSEPTIC SURGERY
are admitted, and along with them the microbes of putrefaction, the products
of which are at first absorbed by the sac and cause the primary toxic fever, but
soon by their irritation convert the pyogenic membrane into a huge granulating
surface which suppurates like an ulcer under water dressing. The tubercle bacilli
meanwhile are allowed to develop at will in the tissues enfeebled by this fresh
cause of disturbance.
Even in abscesses with fetid contents antiseptic treatment is often rewarded
by brilliant success. I once opened an abscess in the lumbar region, giving
exit to a brown liquid, closely resembling thin faeces and with a smell like that
of putrid intestines in the dead-house. Being provided with an antiseptic
dressing, I applied it, and on changing it next day I was, I confess, surprised as
well as delighted to see nothing issue from the opening but a few drops of trans-
parent and odourless serum. Microscopic examination showed the original
contents to consist almost entirely of closely packed very slender bacilli in active
writhing movement ; of what species I know not. Healing took place rapidly
with a typically aseptic course.
In that case I picture to myself the following series of events. The colon
was at some spot affected with inflammation not severe enough to cause death
of its tissues, but sufficiently intense to prostrate for the time the agency by
which, in a healthy state of the bowel, bacteria in the faeces are prevented from
passing through its walls. One or more of this particular species of bacillus,
having traversed the inflamed intestine, developed in the tissues outside the
bowel, and, by a peculiar fermentative action, transformed the effused liquor
sanguinis into the offensive material of the abscess contents. This species of
bacterium, however, while it throve on this foul pabulum, was unable to grow
in pure blood, and when the cavity of the abscess was flushed with liquor san-
guinis effused from its wall after it was opened, the microbe ceased at once to
develop ; and the abscess followed the same course as if no unusual organism
had been present.
Whatever may be thought of this explanation, I venture to urge that all
abdominal abscesses with foul contents (excepting those which obviously contain
faecal matter) should be afforded the chance of following an aseptic course
under antiseptic management.
Submucous abscesses of the rectum pointing beside the anus have always
fetid contents, but if carefully treated antiseptically will, as a rule, heal without
the occurrence of ‘fistula in ano’, 1.e. without the formation of a communication
with the interior of the intestine.’
1 See p. 215 of this volume.
AN ADDRESS ON THE ANTISEPTIC MANAGEMENT
OF WOUNDS
Delivered at King’s College Hospital in the London Post-Graduate Course, January 18, 1
[British Medical Journal, 1893, vol. i, pp. 161, 277, 337, with subsequent Corrections. |
Tuis day five weeks the patient before you was operated on for a badly
united fracture of the patella. He had been kicked on the knee by a horse twelve
months previously. In spite of the care of excellent surgeons his limb was in
a very useless condition. He could not raise it at all in the extended position,
and, in short, he was a complete cripple. When we operated both the upper
and lower fragments were firmly adherent to the bone beneath, and separated
by a considerable interval. The operation was difficult and protracted, but at
length we succeeded in getting the fragments together and fixing them by means
of two stout silver sutures. The patient, as you see, can now walk without a stick ;
he can raise the limb freely in the extended position, and bend it through a limited
angle. A useful limb is already assured to him, and he will no doubt acquire in
course of time a much greater degree of movement than there is at present.
I bring this case before you as an illustration of what may be done by antiseptic
measures. In my opinion, such an operation would be unjustifiable unless the
surgeon could say to himself with a good conscience that he was practically
sure of avoiding septic contamination of the wound. If you consider how terrible
the disaster would probably be if septic suppuration occurred after such an
operation, I think you will see that I am warranted in this view.
I propose, therefore, now to offer a few remarks as to the principles on which
we proceed and the means we employ in order to attain constancy of aseptic
results in our wounds. The matter divides itself into two heads: first, during
the operation to avoid the introduction into the wound of material capable
of inducing septic changes in it ; and, secondly, to dress the wound in such a
manner as to prevent the subsequent entrance of septic mischief.
_ As regards the former of these heads, advancing knowledge has enabled us
greatly to simplify our procedure. When I first entered upon this subject,
knowing as we did that our wounds, with rare exceptions, underwent putrid
suppuration, it was natural to suppose that they were very favourable soils for
the development of septic organisms. We knew from the experiments of Pasteur
that the air of every inhabited place teemed with microbes of various kinds. We
350 AN ADDRESS ON
were in almost entire ignorance of the various species of bacteria, and there was
no reason then to doubt that any of them getting into a wound would produce
serious mischief. Happily, however, we now know the case to be really extremely
different. It is but a small proportion of these organisms which are capable
of doing mischief in surgery ; and even such species as do produce injurious
effects, when they develop in wounds, are by no means always sure of gaining
a footing when introduced into them. This depends upon two circumstances.
In the first place, we have learned that although putrid blood teems with bacteria
of various kinds, some of them in the highest degree pathogenic, normal blood-
serum is by no means a very favourable soil for the growth of bacteria, provided
that they are in an attenuated condition—not in too strong a dose. I may
illustrate what I mean by a simple experiment. If we draw blood, with anti-
septic precautions, say from a horse or from an ox, into purified stoppered
bottles, and simply place them in a stove at the temperature of the human body,
the blood remains permanently unaltered. If we dip the point of the finest
needle into already putrefied blood and touch the blood in one of those bottles
with the needle so contaminated, and replace the bottle in the stove, to an abso-
lute certainty within twenty-four hours the blood is foul and putrid throughout.
But if, instead of applying the putrid blood in substance, I mixed it with an
abundance of sterilized water, so as to diffuse the bacteria widely, at the same
time washing them of their products, I found that a small drop of this diluted
putrid blood, though it contained abundance of bacteria, failed for days together
to induce putrefaction. The grossly putrid material—if I may so speak—
inevitably causes putrefaction in the blood, but the washed and widely diffused
bacteria are unable to do so.*
Then there is another even more important point, and that is that the
living animal body has the power of defending itself against microbes introduced
into it, chiefly, as it appears, by the process of phagocytosis, which Metchnikoff
has revealed; so that if the micro-organisms are not introduced in too large
a dose, they are consumed by the wandering cells. These two great truths, then,
have been taught us by advancing science: that normal serum is not a good
soil for the development of attenuated microbes, and that bacteria introduced
among the tissues, if in not too concentrated a form, are disposed of by phago-
cytosis. The result is that microbes in the form in which they are present in
the air are unable to develop in our wounds ; and thus we are able to disregard
in our operations the once dreaded atmospheric dust.
Hence we may dispense entirely with irrigation, whether in the form of the
spray, which was a kind of irrigation, or in any other ; in fact, our operations
1 See Tvansactions of the International Medical Congress, 1881, vol. ii, p. 372 (p. 281 of this volume).
THE ANTISEPTIC MANAGEMENT OF WOUNDS 351
may be performed with just the same simplicity as in former years. What
we have to attend to is to prevent the entrance into our wounds during operations
of the grosser forms of septic mischief, such, for instance, as exist in impure
sponges, on dirty instruments, or in any unclean material upon our hands or on
the skin of the patient. Then, again, the entourage of the seat of the operation
must be considered. To speak first of this last point, we cover the region round
about the field of operation with towels soaked in a trustworthy antiseptic
solution, and then we are quite sure that if we touch any neighbouring object
there can be no chance of our contaminating the wound as the result of this
contact.
As to the best means of purifying the sponges, &c., it appears that there is,
after all, nothing better than the agent which I happened to employ first—
carbolic acid. There was a time when, in consequence of Koch’s publications
on the subject of corrosive sublimate, it to a large extent displaced carbolic acid
in the practice of surgeons. It turns out, however, that Koch, able as he is,
was misled on a certain point which led him greatly to exaggerate the germicidal
power of corrosive sublimate, and that in truth it is for surgical purposes very
inferior to a solution of carbolic acid in water. It is a happy thing for us as
surgeons that those organisms which have the most resisting spores do not trouble
us in surgical work. For instance, the hay bacillus, which is sure to grow in
an infusion of hay left exposed for a while, has spores of an exceedingly resisting
kind ; but supposing the hay bacillus to get into a wound it would do no harm
whatever. Again, the anthrax bacillus has very resisting spores, but if we take
good care that the catgut which we use for tying bleeding vessels has been
treated with an antiseptic that will certainly kill any spores of anthrax with
which the sheep might have been affected that furnished the intestines for the
catgut, we shall never have any chance of anthrax getting into our wounds.
What we have to deal with as our surgical enemies in the shape of microbes are
almost exclusively sporeless micrococci. Some of these, however, are much more
resisting than others. The Staphylococcus pyogenes aureus
cause of suppuration—is very resisting. Now it has been shown that in such
solutions as would be used in surgery carbolic acid destroys this organism much
more rapidly than bichloride of mercury does."
There is, however, one spore-bearing bacillus with which we have to deal
but too often as surgeons, namely the tubercle bacillus. Some experiments
were made a few years ago by M. Yersin, at the Institut Pasteur, on the germi-
cidal action of various agents upon tubercle bacilli grown in pure culture on
glycerine jelly. I will not enter into the details of his experiments, but if you
a very common
1 See Behring, ‘Ueber Desinfection,’ &c., Zeitschrift fiir Hygiene, Neunter Band, 1892, p. 417-
352 AN ADDRESS ON
refer to his paper ' you will see that they are very beautiful and very trustworthy.
He found that a watery solution of carbolic acid (xz in 20) killed the bacilli in
thirty seconds ; carbolic acid (I in 100) killed them in a minute ; while corrosive
sublimate (I in 1,000), which we had been led to regard as a most potent germicide,
required ten minutes for their complete destruction.
But though the bacilli of tubercle, as grown on glycerine jelly by Yersin,
seem really to have had spores, yet those spores were in a less resisting form than
they assume in the living body. In sputum, for example, they are much more
resisting. Accordingly, I lately asked my colleague, Professor Crookshank, to
make some experiments for me with reference to the tubercle bacilli as they
exist in phthisical sputum, and he has been good enough to do so. I may refer
in detail to the method of procedure. On the 13th of December, 1892, three
guinea-pigs were inoculated under the skin of the thigh with a little of the sputum
which had been subjected for different periods to the action of a solution of
carbolic acid in 20 parts of water. Some of the liquid sputum was introduced
into a test-tube; to this was added the carbolic solution, in volume about five
times that of the sputum. This was shaken up freely and then allowed to stand
at rest, and after a certain time the supernatant liquid was poured off from the
precipitate. Sterilized water was then poured in in abundance, and shaken up
with the precipitate to wash out the carbolic acid ; and of the precipitate which
again formed a little was introduced by means of a sterilized pipette under the
skin of the animal’s thigh. If the bacilli were destroyed, no harm would result
to the animal ; if, on the other hand, they remained alive, the fact would declare
itself in due time by enlargement of the inguinal glands affected by the tubercle.
One portion of the sputum was subjected to the action of the carbolic lotion
for one minute; another portion for an hour; anda third portion for four hours.
Three control experiments were performed; that is to say, three guinea-pigs
were inoculated with sputum which had not been acted on by carbolic acid at
all, but treated in a similar manner with sterilized water. I saw those guinea-
pigs yesterday. The three which were inoculated with the sputum on which
carbolic acid had not acted all had enlargement of the inguinal glands of that
side, showing that tubercle had developed there. The one that had received
sputum acted upon by the I in 20 carbolic solution for one minute had indeed
enlargement, but exceedingly trifling compared with that in the other three.
The two inoculated with sputum on which the carbolic acid had acted longer,
in one case for one hour and in the other for four hours, appeared to have abso-
lutely sound groins ; showing that the tubercle bacilli, in this most resisting
form in which we can find them, had been perfectly destroyed by the carbolic-
* See Annales de? Institut Pasteur, tome deuxiéme, 1888, p. 60.
THE ANTISEPTIC MANAGEMENT OF WOUNDS 353
acid solution, I in 20, acting upon them for those periods of time ; while even
one minute had been sufficient very materially to affect them.
Now this is to me a very satisfactory matter, because it gives experimental
demonstration of the truth, of which I have long been convinced by experience,
that we need not fear tubercle bacilli in our sponges if we keep them for a con-
siderable time in I in 20 carbolic lotion. The way in which our sponges are
treated is this: they are washed well with soap and water, and afterwards with
soda; then thoroughly washed again with water, and finally, after drying,
put to steep in I in 20 carbolic solution till they are again required for use. For
my own part, I purify my sponges for private operations in a somewhat rough
and ready way. I put the sponges after an operation into a tank of water, and
let them putrefy there. The fibrine, which clings among the pores of the sponges,
becomes liquefied by putrefaction. They can then be washed thoroughly clean
of their fibrine, and the washing is continued until they no longer give a red
colour to water. They are then put into I in 20 carbolic solution and kept there.
In my Edinburgh practice I used to proceed in a bolder way. Taking the sponges
out of the putrid tank, I washed them in water, and sometimes, if I was ina hurry,
even before the water which came from them was completely freed from red
colour, I dipped them into the I in 20 carbolic solution, and took them at once
to my operations. I have before now applied a sponge so treated immediately
to a wound for the purpose of exercising elastic pressure and absorbing blood
and serum from it, and then put on my external antiseptic dressing over it
without any bad result. These facts taken together will, I think, be enough to
convince you that it is not necessary, as is sometimes done, to discard these most
valuable articles and substitute for them sterilized cotton-wool or tissue of one
‘kind or another, incomparably inferior to sponges for the purpose of absorbing
blood.
This same I in 20 carbolic solution is what we use for purifying our instru-
ments, our hands, and the skin of the patient. For the instruments, it is very
much more convenient to be able to purify them by a solution like this than to
boil them, as is sometimes the fashion at present. For private practice it would
be a most troublesome thing to have to boil your instruments ; and even when
you had boiled them and brought them sterilized to your operation, it might
often happen that an instrument might fall upon the floor or otherwise come in
contact with some source of contamination. You could not boil it again before
going on with the operation ; but the bath of carbolic lotion at once puts it right.
As to the length of time for which the instruments should be kept in the
solution, a good deal depends upon the care with which you wash your instru-
ments before putting them away. Any which have teeth, such as forceps,
354 AN ADDRESS ON
require special attention. They should always be brushed with a nail-brush
before they are dried, so that there may be no crusts of dried blood upon them
which the carbolic lotion might require a considerable time to penetrate. If
this has been done, a very short period is sufficient for sterilizing. In private
practice I put the instruments into I in 20 carbolic lotion just before the patient
is brought into the room. They continue to be kept in it during the adminis-
tration of the anaesthetic and during our other preparations, and this is quite
adequate for the purpose. It is of great importance that we should not make
things unnecessarily complicated.
So also with the purifying of the skin of the patient. It is not needful to
apply an antiseptic lotion for hours together, as is sometimes done; a few
minutes’ action of the I in 20 carbolic solution is really sufficient ; while its
long-continued operation sometimes produces troublesome irritation. For
purifying the eyelids before ophthalmic operations the carbolic lotion would
excite conjunctivitis. In this special case a weak solution of corrosive sublimate,
applied in compresses, is probably the best. It must, however, be continued
for a lengthened period.
While carbolic acid is more trustworthy as a germicide for surgical purposes
than corrosive sublimate, it is in other respects also greatly to be preferred.
Carbolic acid has a powerful affinity for the epidermis, penetrating deeply into
its substance ; and it mingles with fatty materials in any proportion. Corrosive
sublimate solution, on the other hand, cannot be expected to penetrate in the
slightest degree into anything greasy; and therefore, as the skin is greasy,
those who use corrosive sublimate require elaborate precautions in the way of
cleansing the skin—treating it with oil of turpentine or ether, not to mention
soap and water, to remove the grease which they feel it essential to get rid of
for the efficient action of the corrosive sublimate. Now all this is unnecessary
care if you use carbolic lotion. I can testify to this from very ample experience.
For my part, I do not even use soap and water. I trust to the carbolic acid,
which, by its penetrating power and great affinity for organic substances, purifies
the integument as corrosive sublimate cannot.
Our sponges during the operation are washed with I in 40 carbolic lotion.
You will see how important it must be to have your nurses and assistants careful.
In truth, it needs no small pains to teach them to take the care, simple as it is,
yet all-important, that is requisite for avoiding the contamination of a wound
with gross septic material. Finally, because we cannot be always quite certain
of our assistants being as careful as we wish, before we close the wound we wash
it with I in 40 carbolic lotion. This irritates very much less than the spray,
which applied a stronger solution during the whole operation ; and in proportion
THE ANTISEPTIC MANAGEMENT OF WOUNDS 35
U1
to the diminished irritation there is less serous effusion, and therefore less
necessity for drainage."
Before proceeding to consider the second division of our subject, the best
form of external dressing for the wound, I have a few words to say regarding
the course you might adopt in case you were called upon to operate under
circumstances where you had no chemical antiseptic at your disposal. First,
you should have your sponges well boiled, and also the fine silk threads which
you will use for securing bleeding-points (the ends being cut short). Such
instruments as will not be injured by the process may also be purified in the
same way; and for washing the sponges during the operation it will be well
to use boiled water, although, from the facts before brought under your notice,
you may infer that unboiled water, if free from visible floating particles, would
not be likely to cause mischief. Towels dipped in the boiled water and spread
about the seat of operation will diminish the chance of contamination of the wound
from surrounding objects. Then thorough cleanliness in the ordinary sense,
by the free use of soap and water, must be practised for the hands of the surgeon
and his assistants and for the skin of the part operated on. For sutures under
these imperfect antiseptic arrangements, materials incapable of absorbing
putrescible liquids, silver wire, silkworm gut, or horsehair, should be used
rather than sterilized silk, in order to avoid suppuration in the stitch tracks.
For dressing the wound in the absence of chemical antiseptics, dry sub-
stances such as absorbent cotton-wool or old linen (preferably boiled before use)
are far better than anything kept permanently moist, like water dressing. It
was shown several years ago by Naegeli of Munich that the more concentrated
an organic solution is, the less easily do bacteria develop in it, much in the same
sort of way as a cook who makes her jam has to boil it down until the syrup
has a sufficient proportion of sugar in it, or else fungi will develop in the preserve.
And so the blood and serum oozing into a dry dressing, becoming more or less
inspissated by evaporation, are in proportion a less favourable soil for microbic
development. If we look back to our old experiences with water dressing,
we can only wonder that wounds ever united by first intention at all under
such treatment. The water dressing, clean at the moment of application, was
invariably stinking when it was taken off in the course of twenty-four hours,
and it seems astonishing that septic mischief ever failed to develop in a wound
with this putrid mass lying over its outlet. It only serves to illustrate how
powerful are the means by which Nature defends herself against the microbes.
But with dry dressing, in conjunction with the care in other respects which
* Note by Lord Lister, 1907: In my later practice, when I could feel secure against contamination
of the wound by assistants, I omitted the final washing.
356 AN ADDRESS ON
I have referred to, you would find that complete primary union, instead of being
a rarity as formerly, would be a matter of very frequent occurrence ; although
you would not be at all able to reckon upon the constancy of aseptic results
which may be obtained by the right use of chemical antiseptics.
Iodoform is an agent very much trusted by some surgeons. It is a very
peculiar antiseptic, having extremely little influence over the growth of bacteria
outside the body. That was illustrated by a very simple experiment I performed
a good many years ago. I took two purified stoppered bottles, and put into one
of them cotton-wool strongly impregnated with iodoform—1o per cent. iodoform
wool ; and into the other ordinary absorbent wool. I poured milk from a dairy
into each, just sufficient to soak the mass of cotton, and left them at the tem-
perature of the air. In one of these bottles the milk was thus most intimately
associated with iodoform, yet it soured like that in the other bottle, though
somewhat later, and when I examined a little of the iodoform wool under the
microscope, I found the milk which it contained teeming with bacteria of different
species. That simple experiment was enough to show how little power iodoform
exerts over the growth of microbes outside the body. This conclusion has
since been amply confirmed by the observations of others. It has been even
ascertained, as a matter of experiment, that if iodoform is dusted over sterilized
cultivating jelly in a test-tube, growth will take place from organisms that were
contained in the iodoform itself.
But though such is the case, 1t is nevertheless unquestionably true that
iodoform exercises a powerful antiseptic influence upon wounds. The most
probable explanation of this apparent anomaly is that suggested by Behring,
namely, that iodoform produces its beneficial effects, not by acting directly upon
the bacteria, but by inducing chemical changes in their toxic products. Behring
has ascertained as a matter of fact that some of these toxines are altered chem-
ically by iodoform and at the same time rendered harmless. Two of his experi-
ments, performed in conjunction with De Ruyter, may be quoted in illustration.
A ptomaine obtained from a culture of pyogenic micrococci killed a mouse in
twelve hours when injected pure into the peritoneal cavity, but proved entirely
harmless under similar circumstances when mixed with a little iodoform. Again,
a sample of decomposing pus, which had fatal effects when introduced unmixed
into the peritoneum of the mouse, had no influence whatever upon the health
of the animal if treated with iodoform, which meanwhile left intact the pyogenic
microbes. In the absence of their toxic products, the bacteria could do little
harm, and would probably soon be disposed of by phagocytosis.
* See De Ruyter, ‘Zur Iodoformfrage,’ Langenbeck’s Archiv, 1887, p. 984. Some bacteria are more
affected than others by the direct action of iodoform. Inthespecial case of the cholera microbe it seems
to act asa poison. See Neisser, Centralblatt fiir Bacteriologie, 1888, p. 387.
—————
THE ANTISEPTIC MANAGEMENT OF WOUNDS 357
We seem thus able to understand how iodoform dusted over the cut surfaces
of a wound may have great antiseptic efficacy, more especially as it remains for
a long time unconsumed among the tissues, and is remarkably free from irritating
properties. In circumstances where it is impossible to exclude septic agencies,
as in operations upon the mouth or the rectum, or when putrid sinuses are present,
iodoform is of very high value. Before applying the iodoform in such cases
we mop the cut surface with a solution of chloride of zinc, 40 grs. to the ounce of
water, which has a remarkable power of retarding septic changes in wounds
in the presence of contaminating materials. On the field of battle iodoform
is probably the best means at present at our disposal. Again, in compound
fractures, while we endeavour to purify the wound with strong carbolic lotion,
we cannot be certain of entire success in this respect, and I should be sorry to
dispense with iodoform.
But if you operate when the integument is unbroken, with a sufficient
space around you for the application of a dressing, I would not recommend you
to use it. To apply it to the interior of the wound would be then entirely super-
fluous, provided that you have taken care to avoid its contamination while
operating, and have at your disposal some trustworthy material for preventing
the subsequent access of septic mischief. This, as we have seen, iodoform cannot
be expected to do. A porous material impregnated with it, when soaked through
and through with blood or serum, will allow the microbes of external defilement
to propagate in its substance, though doubtless more slowly than if the iodoform
were absent. It is essentially in the interior of the wound that the virtues of
iodoform are displayed; and the original Vienna practice of dusting the cut
surface with the powder, and applying simple absorbent cotton externally, gave
results which were much extolled at the time, and were probably not far inferior
to those obtained by the use of iodoform wool or iodoform gauze. An iodoform
dressing affords no security against the penetration of septic microbes to the outlet
of the wound. At the same time, it is easy to see that circumstances may often
arise in which iodoform dusted over the cut surfaces may fail to act effectually ;
as, for example, when those surfaces are separated by extravasated blood.
Any material that is merely aseptic, such as cotton-wool or gauze sterilized
by heat, having nothing in its substance to check in any degree the development
of microbes, will allow the septic evil to spread freely to the wound from the
external world, if blood or serum happens to penetrate at any point to the exterior.
In addition to this fatal objection such a dressing has other disadvantages.
The necessary sterilizing apparatus, though it may be provided at a public
institution, cannot well be at the disposal of the private practitioner. And,
further, the merely aseptic material, having no power to correct any accidental
358 AN ADDRESS ON
defilement, must require an almost impossible degree of care in its manipulation.
I have seen this system in operation in very able hands with results by no
means satisfactory.
An external antiseptic dressing, to be ideally perfect, should have four
essential qualities. It should contain some thoroughly trustworthy antiseptic
ingredient ; it should have that substance so stored up that it cannot be dissipated
to a dangerous degree before the dressing is changed; it should be entirely
unirritating ; and it should be capable of freely absorbing any blood and serum
that may ooze from the wound.
The carbolic gauze which we formerly used did, indeed, contain a very
efficient antiseptic ; but this, being volatile, was perpetually flying off in spite
of our endeavours to fix it, and it was a matter of uncertainty in how many days
it might have so far disappeared from the dressing as to leave it untrustworthy.
Carbolic acid had also this disadvantage as an element of an external dressing
that, acting, as we have seen, with peculiar energy on the epidermis, it interfered
seriously with cicatrization, and we were obliged to interpose what we termed
a ‘ protective ’ to shield the healing wound from its action. And this gauze, con-
taining resin for the purpose of fixing the carbolic acid, was not a very good
absorber of blood and serum. Carbolic gauze, then, was not an ideally perfect
dressing.
Corrosive sublimate had the advantage over carbolic acid of not being
volatile. But it was readily washed out of gauze or wool charged with it, and
under some circumstances it proved very irritating. The discharge, passing
from one part of the dressing to another, took up more and more of the bichloride
in its passage, and sometimes became so strong a solution of the salt as to cause
vesication. I endeavoured to remedy these defects by combining the bichloride
with the albumen of the serum of horse’s blood.t. But though the sero-sublimate
gauze answered its purpose, in so far that it contained the bichloride better stored
up and in a less irritating form, it had inconveniences, especially as regards its
preparation, which induced me to abandon it.
The agent which we have found the most satisfactory as the antiseptic
ingredient of the dressing is the double cyanide of mercury and zinc.? Cyanide
of mercury, while it has powerful antiseptic properties, is very soluble and highly
irritating ; but the combination of cyanide of zinc with it has the same sort
of effect, but in a much higher degree, as the albumen of the sero-sublimate
* British Medical Journal, October 25, 1884 (p. 301 of this volume).
* This is a double salt of a very peculiar constitution. It has been specially investigated by Professor
Dunstan, who concludes that it has the following formula: 4ZnCy,, HgCy,. See Tvans. Chem. Soc.,
1892, p. 666. The best way of preparing it was described by Professor Dunstan in the Pharmaceutical
Journal, third series, vol. xx, No. 653.
THE ANTISEPTIC MANAGEMENT OF WOUNDS 359
gauze had upon the bichloride. The combination with zinc keeps the cyanide
-of mercury from being dissolved away, and also prevents it from irritating.
It is, so to speak, chained down by the cyanide of zinc with which it is combined.
The double salt is very little soluble in blood-serum, requiring between two and
three thousand parts to dissolve it; and thus a small quantity of it will last
a long time in spite of a free flow of discharge through it. It thus fulfils the
condition of persistent storage. It is at the same time practically unirritating ;
wounds heal under its immediate contact without the necessity for a protective
layer interposed. Then, as to the essential question of its antiseptic virtues.
Small as is the quantity which serum dissolves, it proves amply sufficient to
prevent bacteric development. Thus in one experiment some serum of horse’s
blood containing 1-5,oooth part of the salt remained clear and odourless for more
than a fortnight at the temperature of the body in spite of inoculation with
putrid material, and even I-10,oooth part prevented all growth for ten days.
When mixed with serum and corpuscles, it prevents putrefaction in smaller
quantity than any other antiseptic with which I am acquainted. The greater
the amount of albuminoid substances in any solution, the more severely is the
antiseptic tested ; and when the red corpuscles are mingled with the serum, as is
the case in the first twenty-four hours after the infliction of a wound, a much
larger amount of the antiseptic is needed than with serum only. Thus four times
as much corrosive sublimate is required to prevent putrefaction in serum and
corpuscles as in serum. Now, the double cyanide answers the purpose in half
the quantity that is necessary with corrosive sublimate. Asan illustration of the
practical value of this material, I may mention a single experiment, not hitherto
published. I packed a piece of glass tube with gauze charged with 3 per cent.
‘of the double salt, and poured into it serum and corpuscles obtained by whipping
pig’s blood. I then inoculated one end of the saturated gauze with a drop of
septic serum, and kept it at the temperature of the body, with provision for
preventing evaporation. After the lapse of five days I found the entire mass
of gauze pure in odour and without bacteric development, as tested by micro-
scopic examination of stained cover-glass preparations of the contained blood.
Meanwhile a piece of unprepared gauze similarly treated showed bacteric
development within twenty-four hours.
But here I must remind you of the essential difference, which must always
be kept in view in considering antiseptic agents, between germicidal and inhibitory
power ; that is to say, between the capability of destroying the life of microbes
and that of preventing their growth while the agent remains in contact with
them. These two properties are by no means similarly proportioned to
each other in all antiseptics. Thus, cyanide of mercury is far superior to the
360 AN ADDRESS ON
bichloride in inhibitory power, but very inferior to it as a germicide. And the
double cyanide of mercury and zinc, while admirable as an inhibitor, is very
feeble as a germicide ; so that we can have no security that materials charged
with it may not contain living organisms. Hence if gauze charged with the double
cyanide were applied dry to a wound, the time might come when, if the dis-
charge were free, the salt, in spite of its slight solubility, might be all washed
out of the deepest parts of the dressing ; and as soon as this should be the case,
living microbes contained in it would be free to develop towards’ the wound.
In order to guard against this risk, we treat the gauze before using it with a reliable
germicide. That which we now use for the purpose is the 1 to 20 solution of
carbolic acid, which, besides being thoroughly effective, has the further advan-
tage that it soon flies off from the dressing and leaves nothing in contact with
the wound but the unirritating double cyanide and cotton fabric.
And now I wish to correct a mistake I made in a former publication.! For
the purpose of destroying any microbes that there might be in the gauze, I recom-
mended a solution of corrosive sublimate, I to 4,000. Now we have seen that
the i to 4,000 sublimate lotion is not nearly so powerful as a germicide as we
then supposed. But it further appears that such power as it possesses is almost
entirely lost as soon as the bichloride comes in contact with the cyanide of
mercury and zinc, when a curious soluble triple compound? is formed which has
extremely slight germicidal action.* The triple salt seems also to be highly
irritating ; and thus, when we used the bichloride of mercury, we failed almost
entirely to obtain the object for which we employed it, and at the same time
lost some of the goodness of the double cyanide, part of which was washed out
in the process, while the resulting solution might cause troublesome irritation.
Soon after I first described this dressing, a surgeon at one of our hospitals came
to me and said he had been using it, and found great inconvenience from it.
He had applied it to a scalp wound, and the whole of the skin covered by the
dressing was excoriated. I found he had applied it soaking wet with bichloride
lotion, and we are now able to understand the irritation that resulted.
It is quite unnecessary to have the gauze wet with the 1 to 20 carbolic lotion ;
mere dampness is sufficient. It may be conveniently moistened as follows :
The gauze is commonly sold in pieces of three or six yards, folded lengthwise
in eight layers. These are unrolled, and half the number to be moistened are
sprinkled roughly with the lotion. The wet and dry pieces are then superposed
alternately, and the whole rolled firmly together; and in a few minutes the
* See p. 319 of this volume.
* See Varet, Comptes Rendus, 1888, vol. cvi, p. 1080.
* For the determination of this fact I am indebted to my colleague, Professor Crookshank.
THE ANTISEPTIC MANAGEMENT OF WOUNDS 361
entire mass will be uniformly damp. This may be done by a nurse, who then
folds the gauze up ina piece of macintosh cloth in which it is kept till it is required
for use, the precaution being taken of turning over the edge of the jaconet so
as to prevent the cotton from coming in contact with the gauze, and abstracting
the carbolic lotion by capillary attraction. Used in this way the double-cyanide
gauze may be absolutely trusted for excluding mischievous microbes ; and we
have seen that it contains the antiseptic element excellently stored up, and that
it does not irritate ; and when I add that it is all that can be desired in absorbing
power, you will see that it approaches very closely to our ideal. And having
now employed it constantly for over four years, both in hospital and in private
practice, with thoroughly satisfactory results, I feel entire confidence in recom-
mending it to you.
Here is a sample of the gauze ready for use. It is, you observe, of mauve
colour, whereas the pure cyanide of mercury and zinc is a white impalpable
powder. I have fully explained elsewhere the reasons for using a dye,’ but
I may here shortly recapitulate them. When the pure salt is diffused in water,
and a piece of gauze is charged by drawing it through the liquid and dried, it
is found that the powder dusts out of the gauze on the slightest touch, and
irritates the nostrils extremely. I first remedied this defect by means of starch ;
and having observed that starch in solution in water becomes attached to the
particles of the double salt and completely precipitated with it, it occurred to
me that perhaps some colouring matter might behave in the same manner as
the starch, and that thus it might be possible to dye the colourless salt, and so
have the means of judging, by the tint of the gauze charged with it, whether or
not it was uniformly distributed in the fabric. I found on trial that various
‘dyes did indeed behave as I hoped, including colouring matters so different as
Prussian blue, logwood, and various aniline dyes. But, what I had not at
all anticipated, it turned out that in the case of some of these dyes, when the
coloured precipitate was diffused in water and the gauze was drawn through
the mixture and dried, without the use of any starch, the objectionable dusting
was avoided. The particles of dye, though in extremely small proportion to
those of the salt, attached them, as it would appear, to the fabric.
When I last published on the subject,? I recommended haematoxylin for
this purpose. But I have since ascertained that the effect is produced still
more satisfactorily by an aniline dye, the hydrochlorate of mauveine, known
in commerce by the name of purified rosalane.* I have here a sample of the
* See p. 325 of this volume.
* Vide loc. cit.
® This dye may be obtained from Messrs. Meister, Lucius, and Briining, of Hoechst-on-Main. I may
here publicly express my thanks to Dr. Perkin, to whom the world is indebted for the aniline dyes, for
LISTER II B b
362 AN ADDRESS ON
J
mauve-coloured powder, the dyed cyanide, as supplied by Messrs. Morson, of
Southampton Row. For charging gauze it is diffused with pestle and mortar
in 1 to 20 solution of carbolic acid in the proportion of about 30 grs. to a pint ;
and the gauze, which must be of thoroughly absorbent quality, is drawn, in
a thickness of about eight layers, through the liquid, which is conveniently
placed in a trough having a bar near its lower part, beneath which the gauze is
made to pass, care being taken that the liquid is kept perpetually stirred to
prevent precipitation of the salt. The gauze is then hung up to dry at the
temperature of the air. The carbolic lotion is used in preference to water, both
because the powder is very much more easily diffused in it and because it is
desirable that any dirty material which the gauze may happen to contain may
be sterilized. A very cheap kind of carbolic acid will answer, and the solution
that drains from the gauze when it is hung up may be used again for the same
purpose. It thus scarcely adds to the expense of the preparation.
This is a very simple process. Fora whole year I prepared my own gauze, for
use in hospital as well as in private practice, before I had satisfied myself com-
pletely as to its value. For hospital use I would advise that the gauze should
be prepared in the institution, so as to save the manufacturer’s charges. In that
case 1t may be taken down and wrapped in macintosh when only partly dry,
avoiding the trouble to the nurses in moistening it.
Gauze may also be easily charged at a few minutes’ notice for emergency in
private practice. I have here a 6-yd. piece of unprepared absorbent gauze folded
lengthwise in eight layers. I soak this thoroughly with 1 to 20 carbolic lotion,
and dust some of the powder roughly over one surface with a pepper-box. I then
roll it together, and kneading it for a minute or two with the fingers, produce, as
you see,a sufficiently uniform diffusion of the salt throughout the mass, as indi-
cated by the colour.t. If this were done by a nurse before the commencement
of an operation, and the wet gauze were wrapped in a folded sheet to absorb
redundant moisture, it would be ready for use when required. A 6-yd. piece
would be an ample dressing for many cases. Now I see by the amount that has
gone from the pepper-box that not more than one-fifth of an ounce has been
used, and as Messrs. Morson supply the dyed cyanide at 20s. per lb., this implies
a cost of only 3d., so that it cannot be regarded as expensive.” If you have no
his kindness in ascertaining for me the chemical composition of rosalane. It is used in quantity equal to
3 per cent. of the weight of the double cyanide, and is applied in watery solution, in which the salt, after
being freed from excess of cyanide of mercury by repeated washing, but before it has been dried, is
thoroughly diffused by stirring. The salt as it precipitates carries the dye down with it, and is after-
wards dried at a moderate temperature.
* A pair of leather gloves may be worn to avoid staining of the hands, or the dye may be washed
from the fingers with spirit of wine.
* I found on weighing this piece of gauze when it was dry that it was needlessly heavily charged,
THE ANTISEPTIC MANAGEMENT OF WOUNDS 363
absorbent gauze at your disposal, linen rags, which are excellent in absorbing
quality, may be quite well charged in a similar manner. This old towel which
has been so prepared, if folded a few times, would make a perfectly satisfactory
dressing. Bandages which it is desirable to render efficiently antiseptic, such
as one that is to be applied next the skin for keeping down the soft parts in
a stump after amputation of the thigh, may be charged on the same principle.
When a free discharge is anticipated we apply a piece of thin macintosh,
sponged with carbolic lotion, over the exterior of the dressing, to prevent the
blood and serum from passing directly through it. This arrangement no doubt
interferes somewhat with the inspissation of the discharges by evaporation,
but this is a matter of indifference when the dressings are efficiently antiseptic.
There is another use to which the dyed cyanide powder may be often advan-
tageously put, namely, treating it with enough of the 1 to 20 carbolic lotion to
make a sort of soft mud or cream which may be applied with a camel’s-hair brush
to parts where there is very little space between the wound and some source
of septic contamination. I have by this means been repeatedly able to avoid
suppuration in the vicinity of the anus, as I otherwise might have failed to do.
The store of the antiseptic salt upon the skin prevents the microbes from working
their way into the wound under the narrow strip of dressing alone available.
There are also situations, such as the pubes, where the cyanide cream applied
to the hairs converts them with great advantage into a part of the antiseptic
dressing.
I may be asked how it was that I obtained uniformly good results when
I used corrosive sublimate solution for the purpose of producing a germicidal
effect upon the gauze ; for I do not exaggerate when I say that during nearly
two years in which I followed this practice I did not meet with a septic failure
when I had an unbroken skin to deal with and a fair field around for the dressing.
This success was no doubt partly due to the shght solubility of the double salt
preventing it from being washed out of the deeper parts of the gauze. But
I attribute it also to another circumstance. I invariably washed a substantial
mass of the gauze which was to be applied next the wound in 1 to 20 carbolic
lotion, in order to get rid of the irritating bichloride which it contained. I thus—
though unintentionally—effectually sterilized, not only this portion of the gauze,
but also neighbouring parts into which the redundant carbolic liquid soaked.
And this mode of procedure, though not so perfect as the systematic moistening
of the entire mass, is a rough-and-ready way of attaining much the same result.
In changing the dressings we make it an invariable rule to cover the wound
containing 7 per cent. of the salt instead of 3 per cent., which is that ordinarily used. Thus the salt
required for such a dressing does not really cost 14d.
Bb2
364 ON THE ANTISEPTIC MANAGEMENT OF WOUNDS
with something reliably antiseptic before we wash surrounding impure parts,
so as to avoid the chance of defiling the wound with them. For these washings
we use the 1 to 40 carbolic lotion. As to the times for changing the dressings,
it is no doubt true that that which is applied immediately after the operation
might in most cases be left untouched for several days. Nevertheless, when
discharge is free, I prefer, as a rule, to remove the first dressing when the first
twenty-four hours have passed. We thus get rid of the serum and corpuscles,
which, while they constitute the largest amount of discharge which occurs in
the case, test, as we have seen, our antiseptic dressings the most severely. The
discharge being still moist near the wound at this period, the gauze is lifted
from it without disturbing it in the shghtest degree ; and I never knew a patient
fail to express himself as feeling more comfortable when the first dressing had
been changed. There are, however, special cases, like a stump after amputation
of the thigh, where an exception may be made on account of the disturbance of
the wound that the changing of the dressing would involve.
In conclusion, I may remark that it pleases me, as the years pass, to see
the hope which I expressed at the International Congress in London eleven years
ago in course of fulfilment, namely, that the use of the antiseptic system would
gradually spread by leavening action throughout the world. At the same time,
I am sorry sometimes to observe that unnecessary trouble is often taken in some
directions while essential points are disregarded in others; so that, with the
best intentions, the best results are not always obtained. I venture to hope
that this address may be of some use to you in directing your attention to the
essential conditions of success.
ON SOME POINTS IN THE HISTORY OF
ANTISEPTIC SURGERY
[Lancet, 1908, vol. i, p. 1815; and British Medical Journal, 1G08, vol. i, p- 1557.]
5
[The following unfinished letter to Sir Hector Cameron was written early in 1906, before the delivery
of his Lectures on the Evolution of Wound Treatment, but never sent to him. I have been assured that
it would have sufficient interest for some readers to warrant its publication. |
My DEAR CAMERON.—It seems superfluous for me to write anything to you
with reference to your coming lectures. - But perhaps in what I shall say, there
may be here and there points which may interest you.
In treating surgical cases antiseptically, I always endeavoured to avoid
the direct action of the antiseptic substance upon the tissues, so far as was
consistent in the existing state of knowledge with attaining the essential object
of preventing the development of injurious microbes in the part concerned.
In compound fracture, to which in 1865, I first put in practice the antiseptic
principle, I applied undiluted carbolic acid freely to the injured part, in order
to destroy the septic microbes already present in it ; regarding the caustic action
which I knew must occur as a matter of small moment compared with the
tremendous evil which it was sought to avoid. But when this had once been
done, no further direct action of the antiseptic upon the tissues occurred. The
carbolic acid formed with the blood a dense chemical compound which, together
with some layers of lint steeped in the acid, produced a crust that adhered
firmly to the wound and the adjacent part of the skin. This crust was left
in place till all danger was over, its surface being painted from time to time
with the acid, to guard against the penetration of septic change into its sub-
stance. Meanwhile, in the undisturbed wound the beautiful result occurred
that the material of the crust within it, and the portions of tissue which had been
destroyed by the caustic, were replaced by living tissue formed at their expense.
That dead tissue, when protected from external influences, was so disposed
of, was a most important truth new to pathology ; and it afterwards suggested
the idea of the catgut ligature.
1 «The Dr. James Watson Lectures delivered at the Faculty of Physicians and Surgeons of Glasgow
in February, 1906.’ Glasgow 1907.
366 ON SOME POINTS IN THE
I do not remember whether you saw the case that led me to apply the
antiseptic principle to abscess. The patient was a woman above the middle
period of life, with lumbar abscess. Taught by the disastrous results that sooner
or later followed the evacuation of such abscesses, whether by valvular opening
or by cannula and trocar, I left the case undisturbed ; till one day, on looking
at it, I found that nothing but epidermis seemed to intervene between the pus
and the external world, so that if left for another day it would in all probability
burst.
I therefore resolved to open it and apply a dressing which should imitate,
as much as circumstances permitted, that which we used in compound fractures.
The pus which escaped on incision was as thick as any I ever saw. Mixing
some of it with undiluted carbolic acid, I applied some layers of lint soaked with
the mixture to the wound and surrounding skin, and covered them with a piece
of thin block-tin moulded to proper shape, such as we used for covering the
crust in compound fracture. This metal covering, which prevented loss of
carbolic acid by evaporation and soaking into surrounding dressings, was fixed
by strapping, and a folded towel was bandaged over it to absorb discharge.
Next day, on changing the dressing, I was greatly astonished to see nothing
escape from the incision except a drop or two of clear serum. What was now
to be done? I had no longer any pus to mix with the carbolic acid. But it
occurred to me that I might make a satisfactory crust by mixing carbolic acid
with glazier’s putty. Accordingly I sent to the dispensary for some whiting and
boiled linseed oil, and making a solution of one part of carbolic acid in four of
the oil, rubbed it up with whiting in a mortar, thus making a carbolic putty.
This I spread on a piece of block-tin and applied it as I had done the first
dressing. There never was any further discharge of pus; the serous oozing
diminished rapidly, and before long healing was complete.
In that case, as there was no spinal curvature, I could not be sure that the
abscess was connected with the vertebrae. But similar results afterwards
followed the same treatment where discharge of bone showed that such con-
nexion existed, and also in suppuration of the hip-joint, whether attended with
shortening of the limb or not, scrupulous care being taken to keep the affected
part completely at rest. The time required for final closing of the sinus was,
however, generally much longer than in the first case.
Precisely the same beautiful result, so entirely novel and so full of deep
interest both for pathology and practice, was seen when acute abscesses were
treated in the same way; the only difference being that in the acute cases the
serous oozing which followed evacuation of the pus came much more rapidly
to a conclusion.
HISTORY OF ANTISEPTIC SURGERY 367
In order to ensure freedom of escape for the serum, a narrow strip of lint
soaked with a solution of carbolic acid in four parts of olive oil was inserted in
the incision. But the antiseptic substance was never from first to last applied
to the cavity of the abscess, as such treatment could only have been productive
of needless irritation. |
I continued to use a strip of lint as a drain for about five years with per-
fectly satisfactory results. But in 1871, having opened a very deeply seated
acute abscess in the axilla, I found to my surprise, on changing the dressing next
day, that the withdrawal of the lint was followed by escape of thick pus like the
original contents.
It occurred to me that in that deep and narrow incision, the lint, instead
of serving as a drain, might have acted like a plug, and so reproduced the con-
ditions present before evacuation. Taking a piece of the india-rubber tubing
of a Richardson’s spray producer that I had used for local anaesthesia at the
operation, I cut holes in it and attached knotted silk threads to one end, so im-
provising a drainage-tube. This I put to steep for the night in a strong watery
solution of carbolic acid, and introduced it in place of the lint on changing the
dressing next morning. The withdrawal of the lint had been followed by dis-
charge of thick pus as before ; but next morning I was rejoiced to find nothing
escape unless it were a drop or so of clear serum. This rapidly diminished, and
within a week of the opening of the abscess I was able to take leave of my patient,
the discharge from the abscess cavity having entirely ceased.
. After that case I used drainage-tubes as a rule in the treatment of abscess.
But it is well to remember that if such a tube should not be at hand, a narrow
strip of lint, sterilized of course with some trustworthy antiseptic solution, will
in almost every case answer the purpose equally well.
The crude carbolic acid which, under the name of German creosote, was
supplied to me by my colleague, Dr. Anderson, Professor of Chemistry in the
University of Glasgow, was a brown liquid which had been adulterated with
water, and this lay on the top as a clear layer, destitute of any flavour of carbolic
acid. This led me in my first paper on compound fracture to speak of carbolic
acid as absolutely insoluble in water.1. But when it was afterwards produced
in a comparatively pure condition in colourless crystals, it proved to be capable
of being taken up by water, though twenty parts were required for the purpose.
The watery solution, however, though weak numerically, showed itself to be
exceedingly potent as an antiseptic. Having applied it to a foul sore in the
palm of the hand, I found, on changing the dressing next day, that all putre-
factive odour had disappeared.
" See p. 4 of this volume.
368 ON SOME POINTS IN- THE
This enabled me to use carbolic acid for washing wounds after operations,
and so to extend the application of the antiseptic principle to surgery in general.
In the state of knowledge at that early period it seemed imperative to apply
a powerful germicide to the wound before closing it. To use undiluted carbolic
acid for operation-wounds, as I had done in compound fracture, was out of the
question ; and carbolic oil, though I did indeed try it, was ill adapted for the
purpose. But the watery solution could be satisfactorily used not only for
washing the wound, but also for purifying the surrounding skin, the hands of the
operator, and the instruments.
The entire absence of carbolic acid in the layer of water on the ‘ German
creosote ’ with which I made my first attempts with compound fractures indicates
that there were present in the crude product substances for which the acid had
incomparably greater attraction than it had for water. When purified from
these substances, it is indeed soluble in water, but only in small amount; and
being so feebly held by water, it is free, when in watery solution, to act upon other
matters for which it has stronger attraction. Thus was explained the remark-
able germicidal energy of a lotion containing only a twentieth part of carbolic
acid, as illustrated by the foul sore in the hand before referred to.
With linseed oil, on the other hand, the acid could be mixed in any pro-
portion, and being firmly held by the oil, it was mild in action, though present
in the large proportion of 1 to 4, as used in the carbolic putty. The 1 to 4
carbolic oil is bland when applied to the tip of the tongue, whereas the 1 to 20
watery solution is intolerably pungent.
The acid in the watery solution, while potent in action when applied, is
soon dissipated, whereas it is slow in leaving the oil. Hence the watery solution,
powerful but transient in operation, was admirably adapted for application
to a cut surface as a detergent, while the carbolic putty, bland in action and
serving long as a store of the antiseptic, could be used with good effect not only
for abscesses, but also as an external dressing for operation-wounds ; and for
that purpose I long employed it. The putty was used in a layer spread on
calico, freely overlapping the skin around the wound, and covered with a folded
cloth to absorb the serum that flowed from beneath its edges. Although
this mode of dressing gave place in time to others which were more convenient,
the change effected under its use at that early period was of the most striking
character: healing without suppuration, pain, or fever, instead of being the
rare exception, became the rule, and operations were safely performed which
had previously been utterly prohibited on account of the danger that attended
them ; while pyaemia and hospital gangrene, which had before been disastrously
rife, were banished from my wards.
HISTORY OF ANTISEPTIC SURGERY 369
Epidermis is a substance for which carbolic acid has special attraction ;
and this, coupled with the facility with which the acid blends with oily matters,
renders it peculiarly fitted for purifying the skin about the seat of operation
and the surgeon’s hands. Another property which aids its action as a detergent
is its great penetrating power, not limited by the products of its chemical action
upon organic substances.
I used the r to 20 watery solution for rendering the patient’s skin and the
hands of myself and my assistants aseptic throughout the 40 years during which
I practised on the antiseptic principle, and I never had any reason to doubt its
efficacy. No long time is required for its action. In my private practice
the purification of the skin was, as a rule, not begun till I entered the patient’s
room to perform the operation. The part concerned was then thoroughly washed
with the r to 20 carbolic solution, and was kept covered with lint soaked
with the same lotion while the instruments were being attended to and the
anaesthetic administered ; the whole process occupying only about a quarter
of an hour. Yet experience showed that this brief period was sufficient.
It may perhaps be argued that under the carbolic putty or any other dressing
containing carbolic acid, that volatile agent was perpetually acting on the skin,
and may have made up for deficiences in the original purification. But during
several years before I gave up practice, the dressings did not owe their virtues
to any volatile antiseptic.
I may mention in illustration one of my latest operations. The patient
was a lady advanced in years, with a large ventral hernia below the umbilicus.
It was producing serious symptoms ; and attempts to reduce it having failed,
her condition had become exceedingly grave. I only began to disinfect the
skin when she was already partly under the influence of the anaesthetic. The
umbilicus contained some drops of opaque liquid of a highly offensive character.
I cleansed its folds carefully with the 1 to 20 carbolic solution, and washed the
skin over and around the sac with the same lotion. The sac was opened by
a median incision, the upper end of which extended to the umbilicus. Into
further details of the operation I need not enter. On changing the dressing
(of cyanide gauze) it appeared that, in her frail condition, the margins of the
skin at the upper end of the incision had lost their vitality over an extent of
about half an inch in length and one-tenth of an inch in breadth at each side.
I afterwards left the dressing unchanged for several days, when I found that
the sloughs, the upper ends of which encroached on the umbilicus, so foul before
the operation, had been replaced by new living tissue, and complete cicatrization
had occurred without the formation of a particle of pus.
I cannot but think it a happy circumstance that the substance which
370 ON SOME POINTS IN THE
I employed first in endeavouring to apply the antiseptic principle should have
been so admirably adapted for detergent purposes. And it has grieved me
to learn that many surgeons have been led to substitute needlessly protracted
and complicated measures for means so simple and efficient.’
As an instance of trouble misapplied in this matter, may be mentioned
preliminary washing with soap and water. If carbolic acid is the disinfectant
used, such washing is not only wholly unnecessary, but is, I believe, positively
injurious ; as it must tend to check the penetration of the germicide into the
substance of the epidermis, by saturating it with water for which carbolic acid
has so little affinity. That this practice is superfluous is, I venture to think,
proved by my experience, as I never in any case adopted it. |
The incomparably greater attraction of carbolic acid for epidermis than
for water was strikingly illustrated by an experiment not hitherto published.
[Here my letter was broken off, in consequence of other engagements. ButI afterwards wrote
to Sir Hector Cameron what I had intended to say on this subject and he was good enough to incorporate
my remarks in his second lecture (see British Medical Journal, April 6, 1907, p. 799).]
“The avidity with which carbolic acid seizes upon epidermic tissues was
strikingly illustrated by an experiment which he related in an unpublished
address to the medical students of Glasgow, delivered in 1894.
‘Having discovered a method by which the amount of carbolic acid present
in a watery solution could be determined,? he packed a test-tube closely with
hair of the human head, and added just enough five per cent. solution of carbolic
acid to cover it, eight times the weight of the hair being required for the purpose.
Half an hour later he poured out some of the liquid, and applied the test ; when it
was found that already nearly half the carbolic acid had been withdrawn by the
hair from the watery solution.
‘Considering that the hair was only an eighth part of the weight of the solu-
* The fear sometimes expressed of poisonous effects from carbolic acid, as used in antiseptic surgery,
is, so far as my experience goes, entirely groundless.
* “In the course of some work on the preparation of catgut for surgical purposes, he observed that
if a weak solution of chromic acid in water is mixed with carbolic lotion, the mixture, which is at first
a pale straw colour, gradually grows very much darker during the next few hours. This fact afforded
the means of estimating the quantity of carbolic acid in a watery solution. Making a mixture of
equal parts of the weak chromic liquid and a five per cent. watery solution of carbolic acid to serve
as a standard of comparison, and at the same time making a corresponding mixture of the chromic
liquid with the carbolic solution to be tested, and ascertaining how much the standard had to be diluted
in order to bring its tint down to equality with that of the mixture containing the liquid to be tested,
an estimate could be formed of the amount of carbolic acid present in the latter. Lord Lister informs
me that, on going over the subject again recently, he ascertained that hair retains this remarkable
power of withdrawing carbolic acid from a watery solution after all fatty matter has been removed
from it by prolonged steeping in sulphuric ether.’
HIstoORY OF ANTISEPTIC SURGERY 371
tion, this was certainly very remarkable. The hair must thus have become
charged with about a sixth of its weight of the antiseptic!; and if a larger
quantity of the lotion had been used, the proportion would have been still
greater.’ ”
* ‘Hair thus highly charged with carbolic acid by washing with five per cent. solution, may some-
times be turned to account in surgery of the scalp as an effective and unirritating antiseptic dressing.
This may be illustrated by one of Lord Lister’s latest cases. The patient was a lady with numerous
atheromatous tumours scattered over the scalp. To have shaved around each of these would have
caused a very inconvenient loss of hair; but this was avoided by washing freely with the lotion about
each tumour, and simply passing a comb along the line where the incision was to run, the hair being
replaced in position after the removal of the cyst. The several tumours having been so dealt with,
a cap of folded cyanide gauze was bandaged over the head, and when this was removed some days
later, all the wounds were found to be healed.’
* On the Evolution of Wound-treatment during the last Forty Years, p.71, and British Medical Journal,
April 6, 1907, p. 799.
2
E
PART IV
SURGERY
REPORT OF SOME CASES OF ARTICULAR DISEASE OCCURRING IN
MR. SYME’S PRACTICE, EXEMPLIFYING THE ADVANTAGES
OFTHE ACTUAL CAUIERY
[Monthly Journal of Medical Science, August 1854.]
CaAsE I.—Omalgia ; Application of the Actual Cautery ; Cure.
MARGARET ASHTON, aet. 25, admitted the 25th of October, 1853 ; a servant ;
has generally enjoyed good health, and has a very robust appearance. Four
months ago, after exposure to wet and cold in washing, she had a severe fit of
shivering, and was seized a few days after with pain in the right shoulder, just
below the acromion, so severe that she could scarcely lift the arm ; this lasted
about twelve hours, and was followed in the course of the next day by intense
pain in the left shoulder, below the back part of the acromion. From that day
till her admission, she was unable to raise the arm; the pain was for the first
two months extreme, keeping her as if ‘in the fire all night’, and banishing sleep
almost entirely. During the last two months she has rested from work, and
has suffered less. On admission she complained of constant gnawing pain in
the left shoulder, and extending down the limb as far as the elbow, and some-
times to the fingers; when in the sitting posture she held the affected limb
with the other hand, to ease the pain ; the arm was also affected with a feeling
of numbness and weakness ; and although the shoulder was not very tender on
pressure, and very gentle passive motion of the arm could be performed, through
a considerable angle, without pain, yet any attempts on her own part to move
it produced great aggravation of her sufferings. As a result, no doubt, of
habitual disuse, the muscles about the shoulder were much atrophied, and this
caused a remarkable apparent prominence of the bony points, viz. the spine
of the scapula, the acromion, the anterior border of the outer part of the clavicle,
and the head of the humerus. The shoulder had an appearance that suggested
at first sight the idea of dislocation.
On the 3rd of November, the patient being under the influence of chloroform,
374 REPORT OF SOME ‘CASES OF ARTICULARSDISEASE
Mr. Syme cauterized thoroughly the skin over the anterior and posterior aspects
of the joint, rubbing a red-hot cautery iron freely backwards and forwards four
or five times over each part. It had the effect of raising and rubbing off the
cuticle, but did not char the skin. An hour afterwards the patient was suffering
but little pain.
Nov. 4.—Said, with a smiling countenance, that she slept well last night,
the first time for four months, and feels now no pain save that of the burns.
Nov. 5.—A poultice was applied yesterday ; the pain of the burn is now
gone, and she feels no pain at all. Says that she has not only lost all pain, but
also that the feeling of numbness is gone from the limb, and that she seems
to have more power init. The burned parts present a white sloughy appearance.
The poultice was continued till the sloughs separated, when simple cerate
was substituted for it, with the view of retarding, rather than promoting
cicatrization.
Nov. 12.—To-day she has been trying to lift the arm, and felt none of the
old pain in the attempt. |
Jan. 31, 1854.—She has to-day left the infirmary. She has for some time
past been gradually acquiring more and more power in the limb ; she can move
the arm backwards and forwards for a considerable extent, and even raise it
slightly. The movements of the forearm are free ; there is no tenderness what-
ever about the shoulder. ‘The return of the use of the limb has been accompanied
with a restoration of the fullness of the muscles, so that there is now no difference
between the contour of the two shoulders. She continues quite free from
spontaneous pain.
I saw her again towards the end of May. She was still quite free from pain,
and there remained only some stiffness about the joint that prevented her from
raising the arm to the full extent.
CAsE II.—Dzisease of Shoulder-joint ; Actual Cautery ; Cure.
Lily Kay, aet. 50, admitted the 23rd of March, 1854. Has generally enjoyed
good health, except that for the last twelve years she has suffered inconvenience
from what she supposed to be rheumatism in the right shoulder, characterized
by shooting pain, occurring more especially when she attempted to lift anything.
In January last the limb became completely disabled from increase of the pain,
which now assumed a gnawing as well as a shooting character, and also began
to be felt in the elbow-joint, and in the arm, forearm, and hand. At this time
she first observed the existence of swelling about the shoulder-joint.
The pain continued to increase till the time of her admission into the infir-
mary, when it was exceedingly severe ; not constant, but frequently keeping
REPORT OF SOME CASES OF ARTICULAR DISEASE 375
her awake at night. She was unable to raise the arm from the side, and had
a sense of weakness in the limb, and some stiffness of the hand. There was
considerable swelling about the shoulder-joint, which was tender on pressure,
particularly at the anterior and posterior aspects. On the day of admission
Mr. Syme applied the actual cautery freely over the anterior and posterior parts
of the joint, the patient being under chloroform. From this time she lost the
old pain entirely, or at least was uncertain whether that which she still felt
was not altogether that of the burn ; and though the pain of the burn was con-
siderable till the sloughs separated, yet it was much less distressing than the old
pain, for which it was substituted, so that she slept much better than before
the application of the cautery. The sloughs came away on the Ist of April,
on which day she had a slight return of the old pain near the wrist, but it has
not occurred again, and she is now (the 4th of April) quite easy. The swelling
about the shoulder has almost entirely disappeared, and there is little, if any,
tenderness ; the sores are granulating healthily.
April 14.—Continues quite easy.
She was discharged on the 27th of April; I saw her about a month after,
and she still continued free from pain.
Case III.—Dzisease of Wrist-joint ; Actual Cautery ; Cure.
Janet Archibald, aet. 32, admitted the 2nd of November, 1853. Rather
a weakly subject. In October last she ‘took a shivering’, without any particular
exposure to cold, and a pricking pain came on in the left wrist, which increased
for a time, and was accompanied with swelling. She applied poultices medicated
with acetate of lead, and under their use a great improvement had taken place
at the end of five weeks, when she got fresh cold in it, as she says, and it became
excessively painful ; the pain continued ever after till her admission, and although
its extreme severity was then somewhat mitigated, yet it kept her awake a good
deal at night ; it was partly dull and heavy, and partly of a shooting character,
and extended down through the hand and fingers. There was also an occasional
tingling sensation in the fingers, and a sense of unnatural weight in the limb.
A great degree of swelling existed about the wrist-joint, particularly on the
dorsal aspect, and this part when manipulated gave a feeling very like that of
fluctuation, so that her medical attendant had been desirous to open what he
had supposed a collection of matter there.
Mr. Syme regarded the condition of the wrist as almost hopeless, but as he
thought suppuration had not yet occurred, he determined to give the limb a
chance with the actual cautery, which he accordingly applied on the dorsal
aspect in two lines, crossing one another over the articulation. The pain and
376 REPORT OF SOME ‘CASES OF ARTICULARK DISEASE
swelling both diminished greatly during the first four weeks after the cauteri-
zation ; some aggravation of the symptoms then occurred for a time, but as
the sore was still open, Mr. Syme thought it unnecessary to interfere further,
and a gradual improvement afterwards took place, till at the time of her leaving
the infirmary (the 14th of February, 1854) there was scarcely any swelling and
very little pain.
I saw her again on the roth of June; there was then no swelling whatever
about the wrist, and no uneasiness except a painful feeling of weakness when
she exerted it much.
CasE IV.—Disease between the Atlas and Axis ; Actual Cautery applied with
great benefit.
Thomas Smith, aet. 27, admitted the 2oth of June, 1854. Generally enjoyed
good health till eighteen months ago, when a stiffness of the neck came on without
any assignable cause, with pain when he turned round his head on the pillow ;
the pain increased greatly, and deprived him altogether of sleep for seven weeks,
during which time he lost three stone in weight. There was severe pain in the
head as well as in the neck, aggravated to an extreme degree by either nodding
or turning of the head, particularly the latter, which, indeed, he at last never
did without turning the rest of the body also. He applied to numerous medical
men in Birmingham, where he lives; and blisters and caustic issues were
repeatedly applied to the back of the neck, but never gave more than very slight
and very transient relief, and he says that from the commencement of his
complaint he never had one minute’s freedom from pain, except during sleep,
till he came here.
At this time he was, according to his own account, about as bad as he had
been at all. His countenance wore a peculiar expression of mingled suffering
and apprehension, as Mr. Syme expressed it. He complained of severe pain in
the neck and head, aggravated by any sudden movement, so that there was
a great constraint about all his actions. He always kept his head bolt upright
except when in bed, and could neither lie down nor get up without supporting
his head with his hands ; he never turned his head without the rest of the body,
but gentle nodding was not very painful. There was great swelling of the
upper part of the neck, and he could only open his mouth a little way ;
deglutition was extremely difficult, and a remarkable prominence of the bodies
of the upper cervical vertebrae was to be felt in the pharynx.
On the day after his admission, Mr. Syme applied the actual cautery over
the spinous processes of the upper cervical vertebrae ; the man was not under
chloroform, and said he hardly knew whether the pain was greater even at the
REPORT OF SOME CASES OF ARTICULAR DISEASE B77
moment than what he had experienced from caustic issues, and immediately
afterwards he told us that he did not feel the pain of the burn at all. Next day
he found less pain in moving the head, and in two or three days his countenance
assumed a cheerful aspect. A steady daily improvement has since taken place
in his symptoms, and at the present time (the 15th of July) he has no pain what-
ever when he sits at rest, and can also use strong and active exertion without
uneasiness, and no longer requires to support his head in lying down or rising ;
he can turn his head round pretty freely and look up to the ceiling, and it is
only in sudden movements of the neck that he feels any pain at all. The swelling
of the neck has greatly subsided, and he can open his jaws wide, and swallow
with comparative facility. The sore on the neck is almost healed, and he talks
of leaving the hospital in a few days as cured.
Remarks.—The above cases speak for themselves ; and I might add several
others, that exemplify in an equally striking manner the beneficial effects of
the actual cautery in certain forms of articular disease. It will be observed
that it is by no means so painful a remedy as is generally supposed, and also
that its good effects are more than can be attributed to the mere discharge of pus
from the sore which it produces, seeing that a great improvement commonly
occurs within a few hours of its application, and long before suppuration is
established.
It is now many years since the use of this means of counter-irritation was
introduced into Great Britain by Mr. Syme; but although a constant series of
successful cases have since continued to demonstrate its value to those who have
witnessed his practice, yet I am satisfied that it has not hitherto been sufficiently
generally appreciated. Case IV is an example of its efficacy against a most
formidable disease, where caustic issues had been long tried in vain. I believe
many limbs and lives have been sacrificed that might have been saved by the
actual cautery, and by it alone; and having been myself very strongly impressed
with the importance of the subject, I should be truly glad if any surgeon who
may have hitherto overlooked it, should be induced by the above report to
inquire more closely into its merits.
LISTER II Gc
ON AMPUTATION
[Holmes’s System of Surgery, vol. iii, third edition. London, 1883.|
PART 1
AMPUTATION is often regarded as an opprobrium of the healing art. But
while the human frame remains liable to derangement from accident or disease,
the removal of hopelessly disordered parts, in the way most conducive to the
safety and future comfort of the sufferer, must ever claim the best attention
of the surgeon. Indeed, the progress of medical science, while furnishing the
means of curing some affections once regarded as hopeless, and thus in one sense
restricting the field for the application of amputation, has in another point of
view extended that field, by improving the mode of operative procedure, and
divesting it of much of its terror and danger ; so that whereas in former times
the removal of a limb was only resorted to in cases of the most serious nature,
it is now often practised when the unoffending member is merely a source of
inconvenience.
It is instructive to trace the history of the improvement of this department
of surgery.
Hippocrates (B.c. 430) recommended only a very rude kind of amputation,
consisting of cutting through mortified limbs at some joint, ‘ care being taken
not to wound any living parts.’ ?
On the other hand, Celsus, who seems to have lived at the commencement
of the Christian era, advised that the removal of gangrenous limbs should be
effected between the dead and living parts, and so as rather to take away some
of the healthy textures than leave any that were diseased ; and as he interdicted
amputating through an articulation, his operations must often have been per-
formed entirely through sound tissues. He directed that the soft parts should
be divided with a knife down to the bone, and then dissected up from it for some
distance, so as to allow the saw to be applied at a higher level. The rough surface
of the sawn bone was then to be smoothed off, and the soft parts, which, as he
tells us, will be lax if this plan be pursued, were to be brought down so as to cover
the end of the bone as much as possible. This method seems calculated to
afford good results ; particularly as it appears probable from his writings that
* Hippocrates, de Articulis, p. 639 of the Sydenham Society’s translation.
ON AMPUTATION 379
re
Celsus employed the ligature for arresting haemorrhage after amputation,’ and
dressed the stump in a manner favourable to the occurrence of primary union.
Archigenes, who practised in Rome shortly after the time of Celsus, paid
special attention to the control of haemorrhage during the performance of the
operation ; and appears to have been the first to employ for this purpose a tight
band or fillet encircling the limb above the site of amputation. But while in
this he did good service, he applied the red-hot iron to the surface of the stump
and also neglected the dissection of the soft parts from the bone, advised by
Celsus, though compensating to a certain extent for this omission by retracting
the integuments before dividing them.’
Galen, who was in truth more of a physician than a surgeon, declined still
more from the Celsian precepts, and reverting to the practice of Hippocrates,
advised amputating through the dead tissues and applying the cautery to the
‘ On this interesting point in surgical history I am disposed to agree with the author of the article
‘Amputation ’ in Rees’s Cyclopaedia, in opposition to the prevalent opinion that Celsus employed the
ligature only in ordinary wounds, and used the actual cautery in amputations. The directions of Celsus
regarding amputation are contained in his chapter on the treatment of gangrene, in which the only
mentjon of haemorrhage is the statement that patients often die of it during the performance of the
operation (tz 7pso opere), referring doubtless to profuse bleeding resulting from ignorance of the circula-
tion of the blood, and of any means of controlling it in the limb. Certainly this expression is no proof
that the cautery was used rather than the ligature ; for the former is the more speedy method of the two.
Neither is the absence of allusion to the ligature in this passage any evidence against its employment
after amputation ; for the argument would apply equally to the cautery, and no one doubts that one
of these two means was used. Celsus, who is remarkable for his extremely concise style, leaves us to
refer to his previous chapter on wounds, in which the subject of haemorrhage is very ably discussed.
In slight cases pressure with dry lint, and a sponge wrung out of cold water, is recommended, or if this
does not answer, lint steeped in vinegar is to be used ; but any portion of dressing retained in the wound
is said to do mischief by causing inflammation ; and on the same principle caustics and other powertul
styptics, though very efficient in arresting the bleeding, are prohibited because they produce a crust,
which acts like a foreign body. In more severe cases the vessels are to be tied ; and finally, ‘ when the
circumstances do not even admit of this,’ the red-hot iron may be used as a last resort.
The only thing that seems to me to give any colour for doubt upon this subject, is the manner
in which the ligature is described, ‘ venae quae sanguinem fundunt apprehendendae, circaque id quod
ictum est duobus locis deligandae intercidendaeque sunt’; language which seems rather to apply to
a partially divided blood-vessel than to one completely severed ; but as the context shows that the
ligature, as used by Celsus, was applicable in the majority of cases, and to more vessels than one in the
same wound, it can hardly be conceived possible that the practice was restricted to the very rare case
of partial division.
Again, there can be little doubt that in drawing down the soft parts over the bone after amputation,
Celsus aimed at primary union, the great advantages of which are strongly insisted on in the same
admirable chapter on wounds ; but it is certain that he knew that the use of the cautery would have
destroyed any chance of union by first intention.
One argument that has been urged on the other side is, that if he had employed the ligature in
amputation, it would hardly have been neglected by his successors: but the slowness of the surgeons
of the sixteenth and seventeenth centuries to adopt it, in spite of the strenuous advocacy of Paré, with
all the advantages of a printed literature, show how little weight is to be attached to this objection.
The utter neglect, during the Middle Ages, of the Celsian method of amputation, and of his simple mode
of treating wounds, may also be mentioned as analogous cases.
* Sprengel’s History of Medicine, French translation, vol. ii, p. 81, and vol. vii, p. 312.
CCc2
380 ON AMPUTATION
residue of the mortified part ;? and for several centuries after his time either
this method or others equally rude and often much more barbarous continued
to be employed.
During the Middle Ages, the ligature, though used for ordinary wounds,
was never thought of in amputation, and whatever may have been the practice
of Celsus in this respect, there is no doubt that the great French surgeon Ambroise
Paré, when he so applied it, in the middle of the sixteenth century, had all the
merit of originality. But, though he urged its superiority over the cautery
with able argument, supported by his extensive experience in both military and
civil practice, yet his teaching failed for a long time to influence surgeons generally,
either in his own country or in other parts of Europe.
The principal reason for this appears to have been that the fillet, which was
the means still in use for controlling the bleeding during the operation, did not
answer its purpose effectually even in the ablest hands: so that the dread of
haemorrhage led most surgeons to prefer the cautery as a more expeditious
method than the ligature. We even find Fabricius of Aquapendente repeating,
in 1618, Galen’s timid doctrine of the danger of amputating through living parts
at all ;? and in 1633 the celebrated Fabricius Hildanus, though describing the
ligature, states that the time which it occupies, and the consequent loss of blood,
make it suitable only for the robust and plethoric, and declares that he ‘ cannot
sufficiently extol the excellence’ of the cauterium cultellare, or red-hot knife,
by which the orifices of the vessels were sealed while they were divided.®
In consequence of this same fear of bleeding, the great object at this period
seems to have been to accomplish the work of severance of the limb as speedily
as possible, and this was often done without any attempt whatever to provide
a covering for the bone. Scultetus, in 1655, depicted the performance of ampu-
tation of the hand by chisel and mallet ; and Purmannus, in his Chirurgia
Curtosa, written as late as 1696, mentions having seen legs removed by two
different surgeons by modifications of a barbarous instrument of the Middle
Ages, a sort of guillotine, ‘ which, by its great weight and sharpness, cuts at once
the skin, flesh, and bones asunder ’ ; but he states that it splintered the bone,
and therefore, ‘all things considered, the ancient way of cutting through the
flesh with a knife, and through the bone with a saw, is more practicable, safe,
and certain.’ *
As an example of the ordinary practice of the seventeenth century may
* Galeni ad Glauconem, lib. ii, cap. xi.
* Hievonymi Fabricti ab Aquapendente Opera Chirurgica, pars i, cap. xCvi.
* “Porro excellentiam hujus cauterli non satis extollere possum,’ Gul. Fabricii Hildani Opera
omnia, lib. de Gangraena et Sphacelo.
* Purmannus’ Chirurgia Curiosa, English translation, book iii, chap. xii.
ON AMPUTATION 381
be mentioned that of Richard Wiseman, Sergeant-Surgeon to King Charles IT.
A fillet having been tightly applied, for the threefold purpose of checking
haemorrhage, rendering the limb less sensitive by pressure on the nerves, and
steadying the soft parts, which were retracted by an assistant, he carried a
crooked knife by a single circular sweep down to the bone, which was divided
with the saw at the same level, and the bleeding was arrested by the cautery,
or some kind of styptic.?
Thus the mode of amputation employed by the father of British surgery
only two centuries ago was precisely that used fifteen hundred years before by
the Roman Archigenes. And very unsatisfactory were the results which it
commonly afforded. The soft parts were insufficient, even in the first instance,
to cover the end of the bone, which was accordingly cauterized, with the object
of accelerating its inevitable exfoliation, and in the further progress of the case
it tended to become more and more exposed by the contraction of the muscles ;
and even if the patient survived the protracted suppuration that ensued, he
suffered more or less from the inconveniences of what has been called the sugar-
loaf stump, being in the shape of a cone, the apex of which was formed by the
prominent bone, covered either by a sore which refused to heal, or by a thin
pellicle of cicatrix, very liable to abrasion.
A great step towards a better order of things was made in 1674 by the French
surgeon Morel, in the invention of the tourniquet,” which though at first but
a rude contrivance, being a stick passed beneath the fillet and turned round so
as to twist it up to the requisite degree of tightness, furnished the basis for the
greatly improved instrument devised in the early part of the following century
by his distinguished countryman, J. L. Petit. This consisted essentially of
two metallic plates, which could be separated from one another by means of
" The ligature, though known to Wiseman, seems not to have been adopted by him. After
describing different modes of applying it, in a way that shows pretty clearly that he had not practised
them, he writes, ‘ But the late discovery of the royal styptic hath rendered them of less use. But in
the heat of fight it will be necessary to have your actual cautery always ready, for that will secure the
bleeding arteries in a moment, and fortify the part against the future putrefaction.’—Chirurgical
Treatises, book vi.
* English surgeons might dispute with the French the honour of the invention of the tourniquet.
In a work written in 1678, published in 1679, entitled Currus Triumphalis e Terebintho, Mr. James Young,
of Plymouth, gives an account of a similar contrivance, apparently produced independently by himself.
He describes it as ‘a wadd of hard linen cloth, or the like, inside the thigh, a little below the inguen ;
then, passing a towel round the member, knit the ends of it together, and with a battoon or bedstaff,
or the like, twist it till it compress the wadd or boulster so very straight on the crural vessels that (the
circulation being stopped in them) their bleeding, when divided by the incision, shall be scarce large
enough to let him see where to apply his restrictives ’ (p. 30). Further on in the book he states that the
same principle is applicable with advantage in amputations of the upper limb. But as he does not
inform us how long he had used this expedient before he wrote the account of it, the credit of priority
must of course be accorded to Morel.
382 ON TAMER iGATTION
a screw, so as to tighten a strap which was connected with them and also encircled
the limb: and it is upon this principle that the ordinary screw tourniquet is
still constructed. From this time forward, except in amputations performed
near the trunk, haemorrhage during the operation ceased to be an object of
dread, and surgeons were at liberty to consider other questions besides mere
rapidity of execution.
The improver of the tourniquet, and our own great countryman Cheselden,
seem to have conceived independently of each other the idea of performing
amputation by ‘double incision’; in which the skin and fat were first cut
through by a circular sweep of the knife and retracted for about an inch, when
the muscles and bone were divided as high as they were exposed."
But this, though a great improvement, had only the effect of diminishing
the cicatrix without covering the bone ;? and Louis, another eminent Parisian
surgeon, believed that in the thigh the objects sought might be better attained
by dividing all the soft parts at once, and sawing the bone at a higher level.
In order to allow the muscles to contract freely when divided, he avoided the
use of the tourniquet, and was the first to employ in its place digital com-
pression of the femoral artery at the groin. He pointed out the important
circumstance that the muscles on the posterior aspect of the thigh, being divided
far from their origin at the pelvis, contract to a much greater extent than those
at the anterior part of the limb, which are connected with the bone where they
are cut; and he showed that, the soft parts having been severed to the bone
by a circular incision and drawn up with a linen retractor, the saw might be
readily applied two and a half inches higher up, after the knife had been carried
through the attachments of the anterior muscles.? This method was amputa-
tion by double incision on a different principle ; and though, in truth, a revival
of the practice of Celsus, was not less valuable than the plan of Cheselden and
Petit, and seems to have afforded results superior to theirs.*
Louis, however, was content if the stump when healed was free from conical
* It is difficult to determine to whom the priority belongs in this matter. Petit in his posthumous
work states, ‘ Je suis le premier qui ait coupé les chairs en deux temps’ ; and also, ‘J’ai imaginé de couper
les chairs en deux temps’ ; and Dieffenbach, in his Operative Surgery, gives 1718 as the date of the intro-
duction of the double incision by Petit. On the other hand, Cheselden as distinctly claims the original
idea in the following passage in his notes to Gataker’s translation of Le Dran’s Surgery : ‘ The thing that
led me to do this was what has too often happened—the necessity of cutting off the end of the stump
the second time. This operation I proposed to my master when I was his apprentice ; but he treated
it with neglect, though he lived afterwards to practise it when he had seen me perform it in the same
hospital.’ This proposal must have been made before 1711, when, at the age of twenty-two, he began
to lecture on anatomy.
* This is well illustrated by the drawing of a stump given by Cheselden in Le Dran’s Surgery, for
the purpose of showing the good effects of the double incision.
* Mémoires de l’ Académie de Chirurgie, vol. ii, p. 286. “ Ibid.; volé v3, paioe:
ON AMPUTATION 383
projection,' and did not aim at forming a complete covering for the bone. This
was effectually done about a quarter of a century later by Alanson of Liverpool,
by dissecting up the integuments for some distance and then dividing the muscles
obliquely, so that they formed a hollow cone, in the apex of which the bone was
sawn ‘ about three or four fingers’ breadth higher than was usually done’. The
effect of this was to ‘ fully cover the whole surface of the wound with the most
perfect ease’ ;? but in the hands of other surgeons the oblique division of the
muscles proved to be a matter of considerable difficulty, and the object was accom-
plished as efficiently and more simply by Mr. Benjamin Bell, of Edinburgh,’
and Mr. Hey, of Leeds, by a combination of the methods of Cheselden and Louis ;
or, as Mr. Hey expressed it, ‘ with a triple incision,’ * in which the skin and fat
were first divided circularly and dissected up for some distance, then the muscles
were cut at a higher level, and these were retracted so as to permit the bone to
be exposed and sawn considerably higher. Mr. Hey added the advice to cut
the posterior muscles somewhat longer than the anterior, to compensate for
their greater contraction ; and thus towards the end of last century, ‘ the circular
operation,’ as it is termed, may be said to have been brought to perfection.
Meanwhile a different principle had been long before suggested and acted
on. So early as 1678, Mr. James Young, of Plymouth, described ‘a way of
amputating large members, so as to be able to cure them fer symphysin in three
weeks, and without fouling and scaling the bone’. The directions given for this
method, the ‘ first hints’ of which he says he had ‘from a very ingenious brother
of ours, Mr. C. Lowdham of Exeter’, are as follows: ‘ You are with the
catling, or some long incision-knife, to raise (suppose it the leg) a flap of the
membranous flesh covering the muscles of the calf, beginning below the place
where you intend to make excision, and raising it thitherward of length enough
to cover the stump; having so done, turn it back under the hand of him that
gripes ; and as soon as you have severed the member, bring this flap of cutaneous
flesh over the stump, and fasten it to the edges thereof by four or five strong
stitches.’® Eighteen years later, Verduin, a surgeon of Amsterdam, ignorant
apparently of what Lowdham had done, provided like him a covering for the
end of the stump from the calf; but, instead of cutting from below upwards,
and only raising the integuments, he thrust a knife behind the bones at the part
1 «L’amputation la plus parfaite est, sans contredit, celle dans laquelle les chairs qui forment
V’extrémité du moignon conservent assez de longueur pour se maintenir au niveau du bout de l’os.’
Op. cit., vol. iv, p. 41.
* Alanson’s Practical Observations on Amputation, 2nd edit., p. 106.
* Benjamin Bell’s System of Surgery, 7th edit., vol. vii, p. 260.
* Hey’s Practical Observations, 3rd edit., p. 527.
* James Young’s Currus Triumphalis e Terebintho, p. 108. A copy of this interesting book exists
in the library of the Royal Medical and Chirurgical Society of London.
384 ON AMPUTATION
where he intended to divide them, and cutting downwards formed a muscular
flap, which he afterwards supported by an apparatus devised for the purpose
of pressing the cut surfaces together so as to check bleeding without the use of
either cautery or ligature.' This machine being complicated and unsatisfactory
was rejected in 1750 by M. Garangeot,? who, substituting the hgature for it,
but retaining in other respects the method of Verduin, brought amputation of
the leg to the form in which it is still often practised at the present day.
The same principle was applied to the thigh, in 1739, by Ravaton, of Landau ;
but instead of one long flap he made two short ones. Having divided all the
soft parts circularly, he thrust a knife down to the bone on the anterior aspect
of the limb, a hand-breadth higher up, and cut down to the circular wound ;
and, having made a similar longitudinal incision behind, dissected up the square
lateral flaps thus formed, and sawed the bone where it was exposed at their
angle of union, and brought them together after tying the vessels.*
Vermale, surgeon to the Elector Palatine, soon afterwards formed the flaps
more easily, and of a shape better adapted for union, by introducing a knife
at the front of the limb and pushing it round the bone at one side, so as to make
it emerge at the opposite point behind, and then cutting a flap of rounded form
by carrying the knife in a curved manner downwards and outwards, the same
process being repeated on the other side.*
The flap operation, performed either by cutting from without inwards or
by transfixion, was occasionally employed by various surgeons in the latter
half of last century; but found its most strenuous advocate in the late Mr.
Liston, and at one time seemed likely to supersede the circular method altogether.
Its great merit in those days of painful surgery was its facility and speed ; for
the flaps were cut with great rapidity, and when they were drawn up by the assis-
tant, the bone was exposed with the utmost readiness at the part where it was
desirable to divide it ; whereas, in the circular operation, to dissect up the ring
of integuments was a somewhat troublesome and tedious process, especially
in a limb increasing in thickness upwards like the thigh, and the use of a retractor
was often necessary, in order that the saw might be applied at a sufficiently high
level.
As regards the immediate results of the two methods, the principal difference
between them was that the flaps, when formed by transfixion, contained a large
amount of muscle, while the circular mode furnished a covering chiefly from the
integument. In this respect the flap operation was at first supposed to have
* Memoires de l’ Academie de Chirurgie, vol. ii, p. 244. * Ebid.; ps 26k
* Ravaton’s Traite d’Armes a feu, p. 405 ; also Mémoires de l’ Academie, vol. ii, P25as
* Le Dran’s Surgery, Gataker’s translation, p. 431.
ON AMPUTATION 385
a great advantage, as providing a muscular cushion for the end of the stump.
But this opinion was shaken by further experience. The muscular part of the
covering, no longer discharging its normal physiological function, degenerates
and dwindles, while the integument tends to become thicker and firmer, so that
the ultimate results of the flap and circular operations present no material
difference. On the other hand, at the time of the performance of the operation,
the method by transfixion has the great disadvantage that the muscular element
in the flap is almost always redundant, and has to be tucked back to permit
the edges of the skin to be stitched together, the natural result being tension
and confinement of discharges and consequent inflammatory disturbance.
In the very case in which the flap operation was first employed, viz. in the
upper part of the leg, the muscular mass proved very inconvenient from its
redundancy when the calf was largely developed ; and even under more favourable
circumstances the heavy and contractile flap was apt to shift from its position
or to drag down the skin of the front of the leg, so as to stretch it on the cut
end of the tibia, and induce ulceration. Hence Mr. Liston himself, so early
as 1839, preferred in muscular subjects a short posterior flap and an anterior
one of the same length, composed of integument only ;! and in the latter period
of his practice he changed this for the following modification of the circular
operation, which was also suggested independently by Mr. Syme, and was used
by him for many years in all cases of amputation in this situation. The skin
and fat are divided by two crescentic incisions with the convexity downwards,
so as to form short antero-posterior flaps of the integument, which is then dis-
sected up considerably higher than their angle of union, after which the operation
is completed as in the ordinary circular method.? This plan gives essentially
the same result as the circular mode, while the raising of the integument is
facilitated, and its edges can be accurately adapted to each other without any
of the puckering that occurred at the angles of the wound after the old operation ;
and experience shows that when the soft parts have been divided in this way
they are quite as favourably disposed for primary union as when cut more
smoothly in the form of flaps.
In the lower part of the thigh also, the presence of the contractile element
in the flaps was found to be injurious by increasing the disposition to protrusion
of the bone, from the action of the powerful hamstring muscles, cut so far from
their origin at the pelvis. Mr. Syme accordingly adapted his modification ot
the circular method to that situation ;* and I can testify to the sufficiency of
the covering which it afforded.
' Liston’s Elements of Surgery, 2nd edit., p. 786.
*Syme’s Principles of Surgery, 5th edit., p. 168. ’ Ibid., p. 170.
) Eery> 5 I
386 ON AMPUTATION
The longer time required for this operation than that by flap was rendered
a matter of no moment by the discovery of anaesthesia in surgery, in the year
1846.1 Independently of the relief from bodily and mental suffering procured
by this great event, it must be regarded as an era in the history of amputation,
of at least equal importance with the invention of the tourniquet ; because,
pain being abolished during the operation, as well as dangerous haemorrhage,
surgeons are now, in the great majority of cases, deprived of all excuse for sacri-
ficing anything, either in plan or execution, to mere rapidity of performance,
and are enabled to regard simply what will most promote the two great ultimate
objects in amputation—safety to life, and usefulness of the stump.
With regard to the latter object, it was till lately an understood thing that
the end of the stump was not adapted for bearing any part of the weight of the
body. Being tender from the presence of the cicatrix, it was not allowed by
the instrument-makers to touch the artificial limb at all; the apparatus being
applied partly to the sides of the stump, but chiefly to some bony prominence
resting on the upper edge of the socket—the tuberosity of the ischium when
the thigh is concerned, and in the leg the internal tuberosity of the tibia, the
head of the fibula, and especially the lower border of the patella.
To this general rule, however, a striking exception was presented by the
amputation at the ankle devised by Mr. Syme, in which the bones are divided
just above the malleoli, where they present a broad surface for diffusing the
pressure over the integument of the heel turned up to cover them, specially fitted
by the character of its epidermic investment and subcutaneous fibro-adipose
cushion for bearing the weight of the body, while the cicatrix lies well forward
out of reach of pressure. The result is that the patient can stand on the end
of the stump as on the natural sole ; and when the deficient spring of the arch
of the foot is compensated by some elastic material contained in a very simple
boot, the limb proves nearly as useful as in its normal condition.
Subsequent experience has shown that similar advantages may be attained
to a greater or less degree in stumps formed by amputation higher up the limb.
It is easy by proper management to ensure the cicatrix falling out of reach of
compression by the end of the bone ; and the integument, though tender in the
first instance, gradually acquires a brawny and callous character when subjected
to regulated pressure, like the skin over the dorsal aspect of the cuboid bone
in talipes varus, and thus becomes able to bear the whole or part of the weight
of the body according to the breadth of the cut surface of the bone, and the
consequent diffusion of the pressure. Indeed, stumps possessing these qualities
were occasionally obtained as long ago as the time of Alanson, who, speaking
* See the essay ‘On Anaesthetics’ (printed in vol. i, p. 135).
ON AMPUTATION 387
of the condition of a patient on whom he had performed amputation above
the ankle by posterior flap, says: “He has been several voyages to sea, and
done his business with great activity. He bears the pressure of the machine
totally upon the end of the stump, and has not been troubled with the least
excoriation or soreness.’? But it is easy to understand why such results were
altogether exceptional so long as the covering for the ends of the bones was
provided by a posterior flap, which, from the force of gravity and the prepon-
derating power of the posterior muscles over those at the anterior aspect of the
limb, must always tend to drop from its original position, and leave some part
of the bone to be covered only by cicatrix. And independently of this, in the
case of the leg, the tibia being covered in front merely by the skin, a scar placed
anteriorly is much more likely to suffer from pressure against the bone than one
situated posteriorly. The amputation of the ankle is, indeed, by posterior
flap; but the full rounded cushion formed by the cup-shaped integument of
the heel renders this an entirely exceptional case. It is plain, therefore, that
with reference to fitness of the stump for bearing the weight of the body, prefer-
ence should be given to an anterior flap, which moreover has the great advantage
of allowing a dependent opening for the escape of discharge.
The recognition of the advantages of the anterior flap is due to the labours of.
two English surgeons, the late Mr. Teale, of Leeds, and Mr. Carden, of Worcester,
working independently of each other, and proceeding by different methods.
Mr. Teale, who had the priority in publication, formed a long anterior and short
posterior flap in the following manner. Having ascertained by measurement
the semi-circumference of the limb where the bone was to be divided, he first
traced with pen and ink upon the skin four lines of that length ; two longitudinal,
extending downwards along the sides of the limb, and two transverse, of which
one joined in front the lower ends of the longitudinal lines, while the other ran
across behind from one longitudinal line to the other at the distance of a quarter
of their length from their upper extremities. Two rectangular flaps of very
unequal lengths being thus mapped out, he raised them, including the muscles
as well as the integuments, by cutting from without inwards, and sawed the
bone at their angle of union; then, after tying the vessels, he bent the long
anterior flap upon itself, that it might ‘ form a kind of pouch for the end of the
bone’, turning up its lower edge to meet that of the short posterior flap, to which
it was carefully adjusted and united by a few points of suture, some stitches
being also introduced where the edges of skin met at the sides of the stump.”
Experience with this method has shown that in properly selected cases it
gives admirable results ; the patient being often able to rest his entire weight
? Alanson, On Amputation, p. 133. * Teale, On Amputation, pp. 34 et seq.
388 ON AMPUTATION
upon the end of the stump ; and even where this is not fully the case, the dis-
tribution of the pressure between the end of the stump and the bony promi-
nences which formerly alone sustained it greatly increases the comfort and
steadiness of locomotion.
Nevertheless it must be admitted that Mr. Teale’s operation has serious
drawbacks. Precise accuracy of execution being essential to its success, it
demands a degree of time and pains which, under ordinary circumstances,
would certainly not be grudged, if really necessary, but which most surgeons
would be glad to be saved, and which sometimes, as in the pressure of military
practice, could not well be given. Again, the cut surface is more extensive
than with ordinary modes of amputation, involving a larger number of vessels
to secure, and also, under some conditions of healing, a more profuse suppuration.
But the greatest objection to this method with a view to its general application
is the high division of the bone which would frequently be required in order
to form the long anterior flap. This defect is of course most marked when the
limb is of considerable thickness at the seat of amputation, and shows itself
in its most exaggerated form in the thigh of a muscular subject. Thus in a
particular instance, where the development was by no means extraordinary,
the dimensions were such that, supposing the anterior transverse incision made
at the level of the upper border of the patella, it would have been necessary, in
order to preserve Mr. Teale’s proportions, to saw the bone eleven inches further
up, or full five inches higher than if the modified circular operation had been
performed. This would seriously have increased the danger, which is always
greater the nearer the seat of amputation is to the trunk,’ while, in case of
recovery, the short stump would have been very inferior in usefulness on account
of the shghtness of the leverage it could have exerted in controlling the move-
ments of an artificial limb.
The same disadvantage would often be experienced in applying the method
to the leg. Near the ankle, indeed, where the limb is small and the anterior
flap short in proportion, the operation is comparatively free from this objection.
But if the circumstances of the case should render it necessary to amputate .
higher in the limb, the rapid increase of the thickness of the calf would necessitate
a high division of the bone greatly out of proportion to the extent of the injury
or disease of the soft parts. Ina leg of about average development the ampu-
tation at Mr. Teale’s seat of election, dividing the bones just below the calf,
would require the integuments to be sound to the level of the tip of the internal
malleolus. But if the skin happened to be unsound to a quarter of an inch
* This principle has been pithily expressed by Dieffenbach in the words ‘ zollweise steigt die Gefahr ’.
(Operative Chirurgie, vol. ii, p. 822.)
ON AMPUTATION 389
above that level, the bones would have to be divided an inch higher; and a
difference of three-quarters of an inch in the skin would involve a loss of two
inches of the bones; and, again, an affection of the integuments implicating
less than two inches above the tip of the malleolus would require a division of
the bones full four inches above Teale’s seat of election. And in the last-named
situation, where the calf is thickest, the very long flap, consisting in the greater
part of its breadth of skin alone, would be very liable to suffer from sloughing.
From considerations like these some of the stanchest advocates of Mr.
Teale’s method are now disposed to restrict it to the lower part of the leg and just
above the knee, where, by turning to account the integument over the patella,
which is not used in ordinary operations, the anterior flap may be made of the
requisite length without specially high division of the bone.
Mr. Carden proceeded upon a much more simple plan, forming a rounded
anterior flap of integument only, without any posterior flap, and retracting
the soft parts somewhat from the bone before dividing it with the saw ; ‘ thus
forming a flat-faced stump with a bonnet of integument to fall over it.’? This
practice he began as early as 1846, nine years before Mr. Teale first employed
his rectangular operation ; and though refraining from publication, he obtained
from that time forward most admirable results, both in safety to life and the
amount of pressure that could be borne by the end of the stump.
It was principally at the knee, where amputation had not previously been
much practised, that Mr. Carden applied his principle. The operation at
this situation is thus described by him. ‘ The operator, standing on the right
side of the limb, seizes it between his left forefinger and thumb at the spots
selected for the base of the flap, and enters the point of the knife close to his
finger, bringing it round through skin and fat below the patella to the spot pressed
by his thumb ; then turning the edge downwards at a right angle with the line
of the limb, he passes it through to the spot where it first entered, cutting out-
wards through everything behind the bone. The flap is then reflected, and the
remainder of the soft parts divided straight down to the bone: the muscles are
then slightly cleared upwards and the saw is applied’ through the bases of
the condyles. ‘Or the flap may be reflected first, and the knee examined,
particularly if the operator be undetermined between resection and amputation.
In amputating through the condyles, the patella is drawn down by flexing the
knee to a right angle before dividing the soft parts in front of the bone ; or if
that be inconvenient, the patella may be reflected downwards.’ ”
This operation, when contrasted with amputation in the lower third of the
' See On Amputation by Single Flap. By Richard Carden, F.R.C.S., &c., p. 6. This is a reprint
of an article in the British Medical Journal, April 1864. * Op. cit., p. 6.
390 ON AMPUTATION
thigh, presents a remarkable combination of advantages. It is less serious in
its immediate effects upon the system, because a considerably smaller portion
of the body is removed, and also because, the limb being divided where it consists
of little else than skin, bone, and tendons, fewer blood-vessels are cut than when
the knife is carried through the highly vascular muscles of the thigh; the
popliteal and one or two articular branches being, as a general rule, all that
require attention, so that loss of blood is much diminished. In the further
progress of the case the tendency to protrusion of the bone, which often causes
inconvenience in amputation in the thigh, is rendered comparatively slight by
the ample extent of the covering provided, and also by the circumstance that
the divided hamstrings slip up into their sheaths, so that the posterior muscles
have comparatively little power to produce retraction. The superiority of
the operation is equally conspicuous as regards the ultimate usefulness of the
stump, which from its great length has full command of the artificial limb, while
its extremity is well calculated for sustaining pressure, both on account of the
breadth of the cut surface of the bone divided through the condyles and from
the character of the skin habituated to similar treatment in kneeling. Consider-
ing, therefore, that this procedure can be substituted for amputation of the thigh
in the great majority of the cases both of injury and disease formerly supposed
to demand it, ‘Carden’s operation’ must be regarded as a great advance in
surgery.
It is also of great value with reference to the general question of the best
mode of amputating in the lower limb. It confirms completely the conclusion
which was, indeed, obvious enough from theoretical considerations, that there
is no special virtue in the rectangular shape of the flaps advised by Mr. Teale,
but that the advantages claimed for his method may be attained by much more
simple means.
Nevertheless to extend the method by anterior flap of skin alone to the
thigh and leg, as advised by Mr. Carden, does not seem to me judicious. A flap
of integument alone, sufficiently long to cover the entire diameter of the limb,
must be liable to the risk of sloughing ; and I cannot but think it wise, when
the muscular element is available for the purpose, to follow Mr. Teale’s example
by including it in the composition of the flap. An operation thus intermediate
between those of Carden and Teale, with a rounded muscular anterior flap some-
what shorter than Teale’s, and compensating for its diminished length and for
the absence of a posterior flap by retracting the muscles before applying the
saw, was practised in the thigh by Mr. Spence, of Edinburgh, before Mr. Carden
published, and yielded very good results." But this operation involves as high
* Edinburgh Monthly Journal, November 1859.
ON AMPUTATION 391
a division of the bone as Mr. Teale’s, and it therefore became an important
question whether its advantages might not be attained by some method free
from this objection. The essential object to be aimed at is that, while the
covering for the bone shall be ample, the tender cicatrix shall be placed suffi-
ciently far back on the end of the stump to be well out of the way of pressure
between the end of the bone and the bottom of the socket of the artificial limb.
And if, consistently with attaining this object, the anterior flap could be shor-
tened and eked out with a short posterior flap, it is plain that in exact proportion
to the extent to which this was done would be the length of bone gained, with
corresponding diminution of danger and increase of usefulness of the stump.
Now it fortunately happens, both in the calf of the leg and in the thigh, that
the bone lies far forward among the muscles, so that even its posterior surface
is considerably anterior in position to the longitudinal axis of the limb. Hence
a flap as long as two-thirds of the diameter of the limb would ensure the scar
being considerably behind the point of pressure; while a posterior flap half
as long as the anterior one would be sufficient to complete the covering. The
posterior flap, being short, may be made of integument only, without any risk
of sloughing, thus getting rid of the bulk, weight, and contractility of a posterior
muscular flap. On the other hand, the anterior flap, being still somewhat lengthy,
should be raised so as to contain a good deal of muscle, which will be useful not
only by ensuring sufficient vascular supply, but also by increasing the thickness
of the cushion below the bone ; while any tendency to retraction that it possesses
(small compared with that of the posterior muscles) will be counteracted by the
force of gravity, through which it will naturally tend to occupy its proper place.
Such was the plan of amputating which I ventured to recommend for the
thigh and the calf in the first edition of this work, on theoretical grounds which
subsequent experience has only tended to confirm. The details of the method,
as applied to these two situations respectively, will be found described in subse-
quent pages.
Before considering the operations best adapted for particular cases of
amputation, it will be well to allude in a general way to the necessary instru-
ments, and the mode of using them.
The amputating knife should have a straight and strong back, and a sharp
point, near which the edge should present a gentle convexity. In the old circular
amputation, a curved knife with a blunt extremity was employed to divide
the integument at one continuous sweep ; but as the modified operation is always
preferable, in which the skin is cut in the form of short semilunar flaps, this
somewhat clumsy implement may now be entirely dispensed with. For a flap
operation performed by transfixion, the blade should be about half as long again
392 ON AMPUTATION
as the diameter of the limb; but when the soft parts are cut from without
inwards, a much shorter knife will answer the purpose, and should therefore
be preferred, as the movements of the smaller instrument can be directed with
greater precision and speed. For removing a finger or toe, something inter-
mediate between the tapering bistoury often used in France and the old round-
bellied English scalpel will be found to combine the advantages of both, without
the inconveniences of either, being equally adapted for piercing and cutting.
In using the knife, the young practitioner will have to unlearn some of the
habits he has acquired in anatomical study. The object being now simply to
divide the resisting textures efficiently, the stroking and scratching movements
of the dissecting room must be changed for a free sawing motion: and for this
purpose the knife must be held firmly in the hand, instead of being kept in the
feeble position best suited for the investigation of delicate structures.
There is another error to which the habits of dissection may lead, far more
serious than a cramped and awkward use of the knife, viz. that of directing the
edge of the instrument towards the skin in raising a flap of integument. Such
a practice, necessary in anatomy, in order to leave the subcutaneous structures
intact, will, if carried into amputation, most seriously endanger the vitality
of the flap, which derives its supply of nourishment from vessels ramifying in
the fat, and must perish if those vessels are extensively divided through scoring
of the tela adiposa. Iam satisfied that integument designed to form a covering
for the stump is often made to slough for want of scrupulous attention to this
simple point.
The skin should always be cut perpendicularly to its surface, for if it is
bevelled off to a thin edge, it is not only unsuited in shape for adaptation with
a view to primary union, but the margin may slough for lack of nutriment.
In transfixing a limb, the direction of the knife must of course be changed
as it passes round the bone, in order that it may emerge at the opposite aspect ;
but it is desirable that this should be done in a continuous manner ; for if the
instrument be thrust in for a certain distance, and then partially withdrawn
and made to follow a new track, the punctured wound first made may cause
very troublesome haemorrhage, if a considerable arterial branch happen to be
divided in it.
In passing the knife round a bony prominence, such as the shoulder, care
must be taken to hold the limb in such a position as shall relax the parts that are
to be pierced, otherwise what might be quite easy may prove impossible ; and
in the latter part of the process, when the point of the knife is advancing in
a greatly altered direction, it is important to keep the back rather than the edge
directed outwards, in order to avoid cutting the base of the flap.
ON AMPUTATION 393
In amputating at a joint, if the tissues are healthy, the division of the soft
parts completes the process, there being no need to take away the articular
cartilage, which is almost as favourably circumstanced for healing as vascular
structures. Thus, when a finger is removed at the metacarpo-phalangeal joint,
the whole wound may unite by first intention ; or if suppuration occurs, the
cartilage undergoes a change into granulations by a process so speedy as hardly
to delay the cure.
The saw, for dividing the bone in other cases, should be broad-bladed,
with a stout back, like the ‘ fine saw’ of the carpenter, and should have small
but well-set teeth. In applying the instrument, its heel being placed upon the
bone, previously cleared of soft parts by a circular sweep of the knife, it should
in the first instance be drawn with firm pressure towards the operator, so as to
make a groove which it will have no disposition to quit in the first forward
stroke. The bone is thus cut precisely at the place desired.
The assistant who holds the limb must take care not to press it forcibly
upwards, otherwise the saw will become locked ; nor must he draw it down-
wards to any great degree, or the bone will break and splinter towards the last.
But the operator should always be so placed as to be able to control with his
left hand the part which he removes. Should any projecting portion be left,
it must be removed with a pair of bone-pliers, which may be substituted entirely
for the saw when the bone is of very small size, as in the fingers. In using them,
the flat surface should always be directed towards the parts that are to be pre-
served, as the other sides of the wedge-shaped blades crush the bone while they
divide it.
The tenaculum, long universally employed for seizing the bleeding vessels
in order to tie them, has been superseded by the catch-forceps, which, like the
bone-pliers, were introduced into surgical practice by the late Mr. Liston. Besides
being always more convenient, they have the great advantage of making the
surgeon independent of an assistant in cases of emergency. The ligature should
be tightly and securely tied, by reversing in the second half of the knot the
relation that the ends of the thread had to one another in the former half, or,
in the language of sailors, by making a ‘ reef-knot’. The larger arteries should
be drawn a little way out of their sheaths, as the best means of avoiding nervous
trunks and other unnecessary tissue. The principal veins also should be tied ;
the dread of exciting phlebitis by such treatment having proved entirely ground-
less. As regards smaller vessels, the old rule was to tie only such as furnished
a distinct pulsating stream. But as the catgut ligature with short-cut ends has
none of the inconveniences of the long threads of silk or flax formerly employed,
there is now no objection to tying mere oozing-points, however numerous ; and
LISTER II pd
304 ON AMPUTATION
this practice has the great advantage that it banishes all risk of reactionary
haemorrhage.
The catgut, of course properly prepared to fit it for surgical purposes, should
be used of as slender quality as will bear the strain of tying ; except in the case
of advanced atheroma, when the finer kinds may be found to cut through the
degenerated tissues of an arterial trunk, and a thicker sort must then be employed
for the principal vessels. If the ligature cannot be made to hold when applied
round the point of the forceps in the usual way, as when fibrous tissue is con-
densed by inflammatory infiltration, the difficulty may always be overcome by
threading a fine curved needle with catgut with both ends long, and passing it
so as to take a substantial hold of the tissues at the site of the bleeding-point,
cutting off the needle, anid tying the two pieces of gut one at each side. The
bleeding vessel will be sure to be included in one of them.
Torsion is preferred by some surgeons; but, though it is admirable for
many wounds, particularly about the face, those who have tried both in amputa-
tion will, I think, agree that the ligature is more unfailing and on the average
more expeditious.
In the second edition of this work I recommended a practice which I had
adopted for some years with great advantage, viz. raising the limb into the
vertical position and pressing it firmly from the extremity towards the trunk
with the view of emptying it of venous blood, and then tightening as rapidly
as possible a screw tourniquet, previously kept perfectly loose. The contrast
between the ‘ almost bloodless’ division of the tissues under such circumstances
and the gush of venous blood which attended the operation when the tourniquet
had been applied in the horizontal or dependent position of the limb was extremely
striking. Soon afterwards Professor Esmarch, of Kiel, published his bloodless
method, which consisted of forcing the blood out of the limb by means of an
elastic bandage applied continuously from the distal extremity to a point some
distance above the site of the intended operation, and then applying another
elastic band just above, to serve as a tourniquet and maintain the bloodless
condition when the continuous bandage was removed. By these means the limb
is rendered absolutely ex-sanguine at the seat of operation.
There can be no doubt of the great advantage of the upper elastic band,
which follows up any yielding of the soft parts and maintains continuously
a perfectly effective constriction; whereas with the common tourniquet, if
the operation was protracted, and especially if the tissues were unusually yielding
through inflammatory or oedematous infiltration, the inelastic strap had to
be further tightened again and again in consequence of recurrence of bleeding.
Esmarch’s elastic tourniquet has thus entirely superseded the old instrument.
ON AMPUTATION 395
But for emptying the limb of its blood the method of elevation seems to me
preferable, if it is used in such a way as to obtain its full advantages, with a
view to which it is essential to understand the modus operandi. Though I first
employed elevation, as others had occasionally done before me, with the object
merely of emptying the limb of its venous blood, I saw before long that much
more than this was really done. If the elevated position was maintained for
a sufficient length of time, the perfectly blanched appearance of the skin implied
that arterioles as well as veins were emptied in a manner that could not be
accounted for on merely hydraulic principles by the effect of gravity upon the
blood ; and being led to inquire into the matter experimentally, I ascertained
that when a limb is raised, the first effect of gravity in emptying and relaxing
the veins is followed by a gradual contraction of the larger as well as smaller
arteries of the limb under the influence of the vasomotor nervous system ; the
effect reaching its maximum in about four minutes.’ If, therefore, the limb
is kept raised to the utmost for about that length of time, care being taken not
to press upon any part containing a venous trunk, and the elastic tourniquet
is then rapidly applied, a degree of bloodlessness of the site of operation is
obtained which is practically as good as that of Esmarch’s method, while it
is free from two objections which attend the latter. One of these is referred
to by Esmarch, viz. that it is inapplicable in case of putrid infiltration of the
tissues, on account of the risk of forcing septic matter into the interstices of
sound tissues; and I may add that I should feel considerable hesitation in
applying the continuous elastic bandage to a part affected with soft malignant
tumour, fearing the possibility of the disease being diffused by the upward
pressure through venous or lymphatic channels. The method by position,
on the other hand, is applicable to all cases. The other objection to Esmarch’s
method which many surgeons have complained of, and which has induced some
to abandon it, is a liability to reactionary haemorrhage. [From this also the
method by position is free. Esmarch’s original elastic band, consisting of a tube
of caoutchouc about as thick as the finger, or a somewhat thinner solid rod
of the same material, is, I believe, the best for the thigh ; because, while it is
exceedingly effective, the abrupt constriction which it produces cannot injure
the nervous trunks, well protected as they are by an abundant padding of muscles.
But in the case of the arm, where the soft parts are comparatively scanty in
proportion to the bone, serious paralytic effects have followed the use of the
elastic tourniquet in this form. These are, however, entirely avoided by
employing for the upper limb, in accordance with Von Langenbeck’s suggestion,
‘ See an Address on the Influence of Position on the Local Circulation, British Medical Journal,
June 21, 1879 (reprinted in vol. 1, p. 176).
Dd2
396 ON AMPUTATION
J
a flat elastic bandage, the pressure of which is more diffused. The elastic tour-
niquet, whichever form is used, should be put well on the stretch, and wound
quickly three or four times round the limb to ensure efficiency of its action.
The elastic bandage is fixed by means of a pin; the rod or tube by tying in a
bow pieces of stout tape previously well secured to its extremities. This may
be done very simply by tying the tape very tightly round the end of the tube
or rod bent into a loop, which cannot escape from the grasp of the ligature.
The only inconvenience attending the elastic tourniquet as compared with
the old instrument is that it cannot be relaxed and tightened at pleasure to show
the bleeding-points, but must be removed once for all. In practice, however,
this difficulty is overcome by searching for the principal arteries in the places
indicated by anatomical knowledge, and, when these have been secured, tying
all points from which any venous blood oozes, by which means the vein and
its accompanying artery will be both included. When this has been done,
it will often be found that not a single vessel requires attention when the con-
stricting band has been removed. But to guard against the chance of any
having escaped notice, the main artery of the limb must be subjected to digital
compression.
The strength of the assistant on whom this duty devolves is often early
exhausted by unnecessary exertion; for the current through an artery lying
over a bone, or some other resisting texture, is completely arrested by a very
moderate amount of pressure directed exactly to the proper part.
A stump after amputation is dressed on the same general principles as other
wounds. When there is much tendency to muscular contraction with its
attendant risk of protrusion of the bone, as in the lower part of the thigh, this
disposition is greatly checked and repose of the stump promoted by a bandage
applied smoothly and moderately firmly from above downwards, while an
assistant draws down the soft parts. In the thigh and also in the leg great
advantage is derived from bandaging upon the posterior surface of the stump
outside the dressing a trough of Gooch’s splint on which the stump rests smoothly,
being rendered independent of movement or irregularity of the pillow. The
end of the stump should not be much raised, as too great elevation interferes
with free discharge, and increases through gravity the tendency to retraction
of the soft parts.
AMPUTATIONS IN THE UPPER EXTREMITY
The upper limb, independently of its smaller size, and the consequent less
shock to the system from the operation, is more favourably circumstanced for
amputation than the lower, in consequence, apparently, of its possessing a better
ON AMPUTATION 397
vascular supply and superior vital power. Thus, it is a more serious thing to
amputate a toe than a finger, and to take away the arm at the shoulder-joint
is a much safer proceeding than to cut off a leg below the knee, even though a
larger wound be inflicted, and a larger portion of the body removed, in the former
case than in the latter. The more advanced in life the patient is, the more do
these differences show themselves. But if circumstances admit of the septic
element being effectually excluded, such considerations have comparatively
little of the weight formerly attached to them.
The particular amputations in the upper extremity will be most conveniently
considered in the order in which they occur from below upwards. The distal
phalanges, though very liable to injury and disease, rarely require amputation ;
for the removal of crushed portions of bone in the former case, or exfoliation in
the latter, will generally leave a useful end to the finger. If it be wished, the
phalanx may be readily taken away by opening the joint across its dorsal aspect,
and, after getting the knife round the base of the bone, forming a palmar flap,
by cutting from within outwards. Or the palmar flap may be first cut by
transfixion ; and this being held up by an assistant, the operation is completed
by cutting straight through the articulation. If the whole distal phalanx be
crushed, amputation through the second phalanx will be best performed by
cutting from without inwards two rounded lateral or antero-posterior flaps,
and dividing the bone with pliers.
Removal of the entire finger is generally preferable to leaving the first phalanx
by itself, which, besides being unseemly, would be a mere incumbrance, except
in the index-finger ; and even there it is of service only in some few handicrafts.
For the middle, or the ring-finger, the operation is best performed according
to the following definite rule. The adjoining fingers being held aside by an
assistant, the surgeon cuts from the prominence of the knuckle in a straight
line towards the middle of the web on one side; but, just before reaching the
web, carries the knife inwards to the fold between the finger and the palm, and,
after making a similar incision on the other side, accomplishes the disarticulation.
The edges of the skin will be found to meet exactly on approximation of the
adjoining fingers, which should be kept tied in that position, to avoid disturbing
the process of union. Remarkably little deformity results from this operation,
so that removal of the head of the metacarpal bone for the sake of appearance
is quite uncalled for. If, however, it is at any time necessary on other grounds
to take away a portion of the metacarpal bone, this can be readily done by the
same method, except that the incisions are made to start from the place on the
back of the hand where the bone is to be divided by the cutting-pliers.
The index-finger may be removed in a similar manner, care being taken, in
398 ON AMPUTATION
making the incision on the side next the thumb, to carry the knife from the
point of the knuckle in a longitudinal direction to near the level of the web
between the fingers, before sloping it off towards the palm, otherwise the flap
will be insufficient to cover the raw surface. A preferable method, however,
is to make dorsal and palmar flaps of rounded form, by cutting from the web
between the fingers to a point on the opposite side of the articulation at a suffi-
ciently high level to allow the end of the metacarpal bone to be taken off obliquely
with pliers, so as to get rid of what would cause an unseemly prominence. But
if it be necessary to remove a considerable portion of the metacarpal bone, the
former method, with the dorsal part of the incision extended upwards, will be
the best.
Similar rules apply to the little finger ; and, in cases requiring it, the whole
metacarpal bone may be removed, by commencing the incision a little above
the articulation with the os unciforme, so as to give space for dividing the liga-
ments after clearing the bone of the muscles which surround it.
Any portion of the thumb is valuable for opposition to the fingers ; but, if
necessary, the whole of it may be taken away by cutting in a curve, with the
convexity downwards, from the web connecting it with the forefinger to the
opposite side of the joint, both on the dorsal and palmar aspects, raising the
rounded flaps, and disarticulating. The whole metacarpal bone may be removed
along with the thumb on a similar plan, by entering the knife a little above
the articulation with the trapezium, and cutting first longitudinally, and then
with a gentle curve to the web, on each side of the bone, then dissecting up the
flaps, and dividing the ligaments of the joint.1 This operation has been often
performed for tumour of the metacarpal bone; but from a case published by
Mr. Syme, it would appear that under such circumstances a useful thumb may
be preserved by excising the bone affected.”
The thumb alone or a single finger, being far more useful than any substitute
should always be retained if possible in cases of injury ; an artificial hand being
afterwards used, provided with a claw, against which the single digit left may be
pressed so as to hold objects firmly.
Amputation at the wrist-joint may be performed by cutting across the back
of the wrist from one styloid process to the other, in a line presenting a slight
concavity downwards, in accordance with the form of the articulation, opening
the joint on its dorsal aspect, then shaping a rounded flap in the palm, raising
* For removing the thumb or little finger with the metacarpal bone, other modes of operating,
somewhat more rapid, but in other respects disadvantageous even when applicable, were recommended
before the introduction of anaesthesia. At present, it appears only necessary to mention such as are
calculated to give the best results.
* Observations in Clinical Surgery, p. 38.
ON AMPUTATION 399
it to the joint, and disarticulating. Another method is to cut the palmar flap
from within outwards after disarticulation ; but the prominence of the pisiform
bone prevents this from being satisfactorily accomplished.
Amputation in the forearm may be performed by antero-posterior flaps. In
front, where the muscles are in larger amount, transfixion may be adopted ;
but behind, the presence of the two bones prevents this, except near the wrist,
where it may be effected, provided the soft parts have their natural laxity, by
pinching up the skin, and passing the knife as close to the radius and ulna as
possible, when, after the integument has fallen back to its usual position, the
extremities of the wound will be placed so far forward that the knife can be
introduced through them in forming the anterior flap. But it is probably always
well to cut the dorsal flap from without inwards, and to raise it so that it shall
consist chiefly of integument, in order that redundancy of muscle and consequent
tension may be avoided. The surgeon standing on the (patient’s) left side of
the limb, and holding it with the dorsal surface towards him, enters the knife
a little to the palmar side of the bone that is the further from him, and cuts
through the skin and fat so as to shape a rounded dorsal flap, terminating the
incision a little to the palmar side of the nearer bone, where he at once pushes
in the point of the knife, so that it may pass in front of the bones and emerge
at the place where the operation was commenced, and cuts a fleshy palmar flap
from within outwards. He then dissects up the dorsal flap ; and the soft parts
being drawn back by an assistant, clears both bones thoroughly about three-
quarters of an inch higher up, and applies the saw. The interosseous artery,
which is apt to retract beside the unyielding interosseous membrane, must always
be secured as well as the radial and ulnar trunks; and if the median or ulnar
nerve is exposed in the palmar flap, it should be shortened with scissors, to prevent
the occurrence of painful symptoms as the stump heals.
There is no objection to amputation at the elbow-joint, in cases adapted
forit. The most eligible plan is to cut a large anterior flap from within outwards,
after transfixing the partially extended limb in front of the joint, bearing in
mind that the line of the articulation is oblique to the axis of the humerus, and
is considerably further below the internal than the external condyle. The flap
being then held up by an assistant, the points of transfixion are connected
posteriorly by a semicircular stroke of the knife, which, besides dividing the
integument, probably detaches the radius, and a few touches with the point
of the instrument will sever the connexions of the ulna. The assistant should
keep the skin of the back of the arm drawn upwards during the operation.
Amputation of the arm presents a good example of the double-tlap operation
by transfixion. The point of the knife being entered at one side of the limb,
400 ON AMPUTATION
avoiding the site of the brachial vessels and nerves, is pushed on in front of the
bone ; and then, by slightly raising the handle, is made to emerge at a place
exactly opposite. The anterior flap is then cut with a brisk sawing movement
of the instrument, which is first directed longitudinally for a short distance, and
then turned gradually towards the surface, and brought out perpendicularly
to the integument. The flap is now lightly raised by the assistant, without any
traction, for this would interfere with transfixion behind the bone, which is
effected through the extremities of the wound already made, and the posterior
flap is cut like the anterior. The assistant now retracts the flaps firmly, when
a circular sweep of the knife exposes the bone about an inch above the angle
of union of the flaps, and another similar turn of the instrument prepares it for
the application of the saw. The edges of the wound meet accurately when
brought together, producing a symmetrically rounded stump. But when the
muscles are largely developed, it is well to avoid the inconvenience occasioned
by their redundancy, by cutting the flaps from without inwards, or by employing
the modified circular method.
Amputation at the shoulder-joint is an operation which yields very satisfac-
tory results, as was strikingly shown by the experience of the late Baron Larrey,
who, during the wars of the first Napoleon, saved ninety out of a hundred cases,
in spite of the very unfavourable circumstances of military practice.’
Of the various methods that have been proposed, that of Lisfranc is the
most expeditious. The arm being raised so as to relax the deltoid, the point
of a long-bladed knife is introduced about midway between the coracoid and
acromion processes, and thrust round the outer side of the joint till it comes
out within the posterior fold of the axilla (or, if the left limb be the subject of
operation, the direction of transfixion is reversed), when a large muscular external
flap is rapidly cut ; and this being held up by an assistant, and the arm drawn
downwards and forwards, the joint is opened by cutting firmly upon the head
of the bone,” which is then raised from its socket so that the knife may be passed
round it, and carried downwards along the inner surface of its neck and shaft,
followed by the other hand of the assistant, which grasps the tissues that lie
between the track of the instrument and the axilla, so as to prevent bleeding
from the main artery, when it is divided in the completion of the short
internal flap.
This operation, however, is rarely available in practice. Its satisfactory
performance requires the leverage of the humerus, which is generally broken in
* Memotve de Chirurgie militaire, par le baron D. J. Larrey, tome iv, p. 434.
* Strictly speaking, this is Dupuytren’s modification of the method of Lisfranc, who depressed
the arm at the commencement of the operation, and opened the joint during the transfixion ; but this
was a less easy proceeding, though shorter by a few seconds in very expert hands.
ON AMPUTATION 401
cases of injury demanding removal of the limb, in which also the parts necessary
for the large external flap are often encroached on ; and in tumour of the bone,
which is the other affection that most frequently calls for amputation in this
situation, transfixion becomes inadmissible.
On the other hand, Larrey’s mode of operating, by lateral flaps of equal
size, proved almost always applicable in his cases of gunshot-wound, while it
was as secure against haemorrhage as that of Lisfranc. Thrusting the point
of a knife of moderate length down to the bone immediately below the acromion
process, Larrey first made a longitudinal incision about two inches in length,
from the extremity of which he cut in a curved line at each side of the limb to the
fold of the axilla ; then dissected up the muscular flaps so as to expose the articu-
lation completely, a finger of an assistant being placed upon the divided circumflex
artery ; and, having severed the connexions of the head of the humerus, passed
the knife round it, and kept the instrument close to the inner side of the bone,
till, turning the edge towards the surface, he last of all divided transversely the
tissues intervening between the axillary folds, containing the artery, previously
commanded by the hand of the assistant following the knife.’
This operation is improved by dividing the structures between the folds of
the axilla obliquely, as part of the internal flap, the lower portion of which is
reserved to be cut from within outwards, at the conclusion of the operation :
the result being two precisely similar semilunar flaps, meeting above at the
acromion and below at the posterior fold of the axilla, adapted for immediate
union throughout their length, and presenting as small a wound as is consistent
with an efficient covering.
When the bone is broken near the joint, it will be found useful to adopt
Mr. Syme’s expedient of introducing the finger into a longitudinal wound in the
capsule, for the purpose of drawing down the head of the bone so as to gain
access to its attachments. In some cases of tumour it may be necessary to raise
all the soft parts, including the axillary vessels, from without inwards ; when
haemorrhage must be restrained by compression of the subclavian artery over
the first rib, by the thumb of an assistant pressed down behind the collar-
bone.
Sometimes it may be best to make a large superior flap, cut from without
inwards, containing the whole width and chief length of the deltoid muscle ;
but circumstances will often arise in which no regular rule can be followed, and
the parts that happen to be sound must be turned to the best advantage, accord-
* During one period of his practice, he formed the lower parts of the flaps by transfixing from the
end of the longitudinal incision to the borders of the axilla, and cutting from within outwards ; but
the method given in the text is that to which he ultimately gave the preference. See Larrey’s Clinique
chirurgicale, 1829, p. 563.
402 ON AMPUTATION
ing to the judgement of the operator. Even when a large raw surface 1s left,
the granulating process will complete the cure, as is well illustrated by some of
Larrey’s cases, which terminated satisfactorily after extensive loss of the soft
parts of the shoulder and removal of portions of the scapula.
AMPUTATIONS IN THE LOWER EXTREMITY
The distal phalanx of the great toe may be removed in the same way as that
of a finger. When one of the smaller toes is in a condition requiring amputation
at all, it should be taken away entirely, since any portion left would be likely
to prove inconvenient from being tilted upwards. The operation is exactly
similar to that for a finger ; but it must be borne in mind that the articulation
with the metatarsal bone, which is the starting-point for the incisions, is much
further behind the web than the corresponding joint in the hand, in proportion
to the size of the digit.
When the whole great toe is removed, or the little toe, the prominent part
of the head of the metatarsal bone must be cut off by an oblique application
of the bone-pliers, as it would prove inconvenient if left. The longitudinal
part of the incision in the soft parts should be placed on the dorsum of the foot,
to avoid the inconvenience that might arise from pressure on a scar at the lateral
aspect. In amputating the great or little toe, together with the whole meta-
tarsal bone, it is best to proceed as in the analogous operation for the little finger,
the incision being commenced on the dorsum of the foot, about a quarter of an
inch behind the articulation with the tarsus, and carried longitudinally to near
the metatarso-phalangeal joint, where it bifurcates to embrace the root of the
toe. The knife, which should be a strong one, is then applied with a short
sawing action close to the metatarsal bone and its articulation with the toe, so
as to clear them completely ; and the ligamentous attachments of the base of
the bone are lastly divided with the point of the instrument. In the case of
the great toe, it is especially important to keep the knife well under command,
and avoid thrusting its point deeply into the sole; for this, besides inflicting
unnecessary punctures, may wound the plantar artery at a part difficult of
access. This mode of removing the great or little toe and its metatarsal bone,
though not so rapid as that of dissecting up a flap from the side of the foot, then
cutting between the toe to be removed and the adjoining one, and disarticulating,
has the great advantage of avoiding any scar in the sole.
If more metatarsal bones than one require removal, the incision must be
begun in the same way, but made to include the roots of all the toes concerned,
so as to form a dorsal and a plantar flap ; and even in case of caries in the articu-
lation between the tarsus and metatarsus at one side, a useful foot may be left
ON AMPUTATION 403
after taking away the bones affected, by means of a similar incision commenced
further back.
The separation of the whole metatarsus from the tarsus is an operation
seldom called for ; but it is evident, from the account given by the late Mr. Hey,
of Leeds,? who introduced it, that it affords excellent results. When the state
of the soft parts permits, the ends of the exposed tarsal bones should be covered
with a long flap from the sole, turned up to unite with the dorsal integument,
cut very short ; so that the cicatrix, being on the upper part of the foot, may
be out of the way both of pressure in walking and of contact with objects in
front of it. In performing the operation, it must be remembered that the
tarso-metatarsal articulations are not in a regular line, but that the base of the
second metatarsal bone is locked between the first and third cuneiform bones,
of which the former is the more prominent, and is connected laterally with the
second metatarsal by a very strong interosseous ligament. To divide this
ligament, Lisfranc adopted the plan of thrusting an amputating knife obliquely
downwards and backwards between the first and second metatarsal bones into
the substance of the sole, the tissues of which served as a fulcrum, supporting
the point of the instrument, when its edge was urged forcibly between the bases
of the bones by pushing the handle backwards. This, however, is a needlessly
rough proceeding ; for by pressing firmly back between the bases of the bones
a strong and short knife, such as ought to be used for the rest of the operation,
the ligament may be cut without difficulty ; after which all the articulations
are readily separated by scratching through the dorsal and other ligaments
with the point of the knife, while the metatarsus is strongly depressed.
The secret of facility in the operation lies in hitting the line of the articu-
lations ; but this is readily enough done by finding first the joints of the first
and fifth metatarsal bones, and bearing in mind that the others lie in a line
between them, slightly convex forwards, interrupted by the recession of the
second bone. The prominence of the base of the fifth metatarsal indicates the
situation of its joint, and, if the parts be in a natural condition, the articulation
of the first metatarsal with the first cuneiform can also be felt. Should inflam-
matory thickening obscure the position of the latter, it might be well to measure
the distance of the corresponding joint from the internal malleolus on the sound
foot ; or assistance may be derived from the circumstance that the joint lies
midway between the malleolus and the metatarso-phalangeal articulation.
These points having been precisely ascertained, the surgeon grasps the fore
part of the sole with his left hand, placing the tip of the forefinger at one of the
joints, and the thumb at the other, to mark their position, and cuts firmly across
* Hey’s Observations, p. 555.
404 ON AMPUTATION
the dorsum of the foot in a line slightly convex forwards, a little anterior to the
articulations, taking care that the incision commences and ends fairly in the
sole. He then opens the joints of the first and fifth metatarsal bones, so as to
ensure finding the line of the articulations afterwards, and next shapes a long
plantar flap by an incision extending from the extremities of that already made
along the sides of the foot and roots of the toes, dissects up the flap from the
bones, and completes the disarticulation in the manner above described.
When the anterior part of the sole is unsound, a shorter plantar flap and
a proportionately longer dorsal one may be made, as recommended by Sir Astley
Cooper.*
Sometimes the proceeding may be greatly simplified by sawing through
the metatarsal bones a little anterior to their’ bases, and so avoiding disarticu-
lation altogether. This method would probably have another advantage, from
making the stump of the foot longer and therefore a more effectual lever for
opposing the muscles which act upon the calcaneum through the tendo Achillis ;
for experience has shown that when the foot is much shortened, the heel is apt
to be drawn up, so as to cause the end of the stump to point more and more
towards the ground, producing lameness or entire inability to walk. This has
been noticed especially after Chopart’s amputation through the tarsus, which
is consequently an undesirable operation, even in cases of injury : while in caries
it is further objectionable, because the part of the tarsus left behind, though
apparently sound at the time, may become affected with the same disease at
a later period.
If it be wished, however, Chopart’s operation may be performed on the
same principle as Hey’s, by making a very short dorsal flap, and a plantar one
reaching to the balls of the toes, to cover the exposed anterior surfaces of the
astragalus and os calcis. The articulation between them and the navicular and
cuboid bones will be found in a line running across the foot, through a point
midway between the external malleolus and the base of the fifth metatarsal
bone.
In the amputation at the ankle devised by Mr. Syme, the bones of the leg
are divided just above the bases of the malleoli, a covering for the osseous surfaces
being provided from the integument of the heel; the result being a stump
admirably fitted for bearing the weight of the body. At the same time, the parts
likely to originate carious disease are completely got rid of ; so that this operation
is calculated to supersede entirely that of Chopart, besides taking the place of
amputation of the leg in the majority of the cases formerly supposed to demand it.
The operation should be performed as follows. Provision being made against
* Surgical Lectures, edited by Tyrrell, vol. ii, p. 432.
ON AMPUTATION 405
haemorrhage by the pressure of the thumb and finger of an assistant, placed
respectively on the middle of the fore part of the limb and behind the tibia,
about two inches above the joint, so as to control the anterior and posterior
tibial arteries, or by an elastic tourniquet above the knee, and the foot being
held at right angles to the leg, the surgeon puts his left hand behind the heel,
with the finger and thumb on the places where the incisions are to commence
and terminate ; these being the tip of the external malleolus and the point exactly
opposite on the inner side, 1.e. not at the tip of the internal malleolus, but con-
siderably below and behind it. With a knife, short and strong both in blade
and handle, he now cuts down to the bone across the sole, from one of these
points to the other, in a plane either vertical or sloping slightly towards the heel
when that part is unusually prominent; and then, extending the foot, joins
the horns of this incision by another running as straight as possible across the
front of the ankle. He next dissects up the posterior flap from the os calcis,
keeping the edge of the knife close to the bone with the guidance of the left
thumb-nail, till the point of the calcaneum is fairly turned, when he proceeds
to open the joint in front, divides each lateral ligament with a stroke of the
knife applied between the malleolus and astragalus, and completes the removal
of the foot by severing the tendo Achillis. He then prepares the bones of the
leg for the application of the saw ; taking care, when cutting behind the tibia,
to keep close to its surface, from which the posterior tibial artery is separated
only by a little loose cellular tissue ; and lastly, he takes off the malleoli along
with a slice of the intervening part of the tibia, sawing exactly perpendicularly
to the axis of the liimb—that is to say, directing the saw vertically and trans-
versely while the leg is kept horizontal.
It is a common mistake to make the inner end of the incision at the internal
malleolus, instead of opposite the extremity of the outer one. This has two
bad effects : it renders the flap unsymmetrical, and, what is far worse, it makes
it unnecessarily long, and thus introduces an element of difficulty and risk
into an easy and safe operation. For when the incision is carried forwards
into the hollow of the foot, it becomes a most troublesome task to turn back
the integument over the prominence of the heel; and the knife being thrust
the operator knows not where, the subcutaneous tissue containing the vessels
on which the skin depends for its nourishment is punctured and scored, and
perhaps the point of the instrument itself appears occasionally through the
skin itself, while the flap is subjected to violent wrenching in the effort to draw
it back over the bony projection. Under such a combination of unfavourable
circumstances, it is but natural that it should slough.
On the other hand, when the flap has been made as above directed, in
406 ON AMPUTATION
accordance with the latest recommendations of the author of the operation,
it applies itself with perfect uniformity to the surface it is designed to cover,
and has no disposition to shift to one side in the after progress of the case ; and
every stroke of the knife by which it is raised being made under the eye of the
surgeon, without any forcible traction, it is as little liable to slough as any other
portion of integument with an equally broad base and an equally rich vascular
supply. Even the integrity of the posterior tibial artery, though desirable,
is by no means essential, provided the rest of the subcutaneous tissue has been
left uninjured. Many persons, in discussing the merits of this operation, seem
to assume as an axiom that sloughing of the flap must occasionally take place ;
but I am persuaded from very extensive experience that, if the skin of the heel
be sound, such an occurrence will always be the fault of the surgeon.
Hence the various modifications of the original method that have been
suggested, though commonly discussed chiefly with reference to a fear of slough-
ing, must be judged of entirely on other grounds. Thus the plan introduced
by the late Dr. Richard Mackenzie, of Edinburgh, of making the base of the
flap at the inner side, that it may have a more free supply of blood from the
posterior tibial artery, is not to be regarded as a substitute for the simpler method
of a posterior flap; yet it proves useful in case of unsoundness of the integu-
ment on the outer side of the heel ; and it is probable that an external flap might
be made with equal advantage if the internal aspect of the limb were affected.
At the same time it may be worth while to remark that the mere presence of
sinuses at either side is no ground for deviating from the original procedure ;
and, further, that no degree of complication of sinuous tracks ought to induce
the surgeon to amputate in the leg and deprive his patient of the greatly superior
stump afforded by Mr. Syme’s amputation.
The operation of the late Professor Pirogoff, of Petersburg, in which the
posterior part of the os calcis is sawn off and turned up as part of the flap, to
unite with the cut end of the tibia, has the disadvantage in cases of caries that
it entails a risk of recurrence of disease in the portion of the calcaneum remaining.
It is also more complicated than Mr. Syme’s method, from the necessity of
accurate adjustment of the osseous surfaces, with a view to the best position
for the posterior flap. For this purpose both bones are cut obliquely ; the
tibia in a plane looking somewhat backwards as well as downwards, and the
os calcis in one that is directed somewhat upwards as well as forwards ; so that
when the cut surfaces are applied to each other, the dense plantar integument
covering the lower part of the calcaneum is presented downwards for supporting
the weight of the body, rather than the thin skin over the posterior aspect
* See Mr. Syme’s Clinical Lectures in the Lancet, 1854.
ON AMPUTATION 407
of the bone. If these points are attended to, Pirogoff’s amputation gives a
thoroughly useful stump in cases of injury. But I am not aware that it has
any advantages over that provided by Syme’s operation, and the increased
length of the stump which it produces is rather objectionable than otherwise ;
for with the original operation, the space afforded for the artificial foot is not
more than the maker finds convenient.
When the ankle-joint is affected with caries, the saw should be applied
at a higher level than usual to the tibia and fibula, and the vertical articular
surfaces by which the joint is continued upwards between those bones should
be removed with cutting pliers, to guard against recurrence of disease in that
situation.
In cases which do not admit of Mr. Syme’s operation, amputation imme-
diately above the ankle should be performed if possible, in preference to that
at ‘the seat of election’, a little below the knee; for, although the use of the
knee-joint may be retained even with a very short stump, the longer one gives
greater command over the artificial limb, and the operation involves less risk
co Lite;
Different methods may here be employed. One mode is to make a short
semilunar anterior flap cut from without inwards, and a large posterior one
formed by transfixing behind the bones and cutting downwards and outwards,
the saw being applied a little above the bases of the flaps ; or antero-posterior
skin flaps of equal length may be made, and the bones divided somewhat higher
up. Or again, the modified circular operation? is applicable in this situation.
But the method by longer anterior flap is greatly to be preferred to any
other, on account of the excellent covering it affords, with the cicatrix out of
the way of pressure, enabling the stump to sustain the whole or a considerable
part of the weight of the body on its extremity. The principles on which the
operation should be performed have been already fully discussed in former
pages,” but a modification of the plan there indicated is called for on account
of the difficulty of retracting the soft parts from the bones. This arises especially
from the intimate attachment of the muscles to the fibula; but if these are
divided through an extension upwards of the outer longitudinal incision, no
difficulty is experienced, unless the tissues are condensed by inflammatory
thickening, in effecting retraction of the remaining soft parts from the tibia
without dividing the skin at the inner side to a higher level than the typical
operation demands. Another point requiring special attention in the leg,
as compared with the thigh, is the raising of the anterior flap. The anterior
tibial artery, on which the flap depends for its nutrition, lies close to the inter-
A See p. 385. * See pp. 387 et seq.
408 ON AMPUTATION
osseous membrane, and would be very lable to be punctured during the dissection
if we did not follow Mr. Teale’s advice in conducting it. He pointed out that
in consequence of the looseness of the cellular connexions of the interosseous
membrane, there is no difficulty in separating the parts in front from its surface
with the finger-tip, while dividing with the knife the attachments of the muscles
to the bones.t. In this way, the vessel is secured from any chance of injury.
Immediately above the ankle the operation is performed as follows. The
diameter of the limb having been ascertained by spanning it, a straight longi-
tudinal incision of that length is made at the inner side of the leg, and on the
outer aspect another similar incision directly over the fibula and extending
about an inch higher up. The lower ends of these incisions are connected by
cutting across the front of the limb in a direction transverse in the main, but
rounded off where it joins the lateral lines. The knife is next carried round
the back of the limb to the bones from the upper end of the internal incision
to a point exactly opposite on the outer side, which will be about an inch below
the upper end of the outer incision; the instrument being carried in a line
slightly convex downwards, so as to form a very short posterior flap. The
anterior flap is then raised in the manner above mentioned, including every-
thing in front of the bones and interosseous membrane ; after which the tibia
and fibula are cleared as high as the level of the upper end of the outer incision,
the finger-tip being still used in detaching the parts anterior to the interosseous
membrane. .
In order to avoid splintering the fibula, it is best to saw both bones at the
same time, and to finish the fibula before the tibia. The sharp angle of the
spine of the tibia being apt to cause ulceration of the skin over it, should be
removed ; and the most convenient way of doing this is to commence with
sawing obliquely for a short distance from a point about half an inch above
the place where the bones are to be divided transversely. Supposing effectual
antiseptic treatment employed, the cutaneous margins of the flaps may be
stitched very closely, except at the upper end of the outer incision, which is
left open for the drain, and serves admirably for the purpose, as it leads directly
from the cut surfaces of the bones, and is dependent in position from the circum-
stance that the limb reposes on its outer side. Accurate stitching is desirable
elsewhere, in consequence of the disproportion of the sizes of the two flaps,
which, however, is diminished by making a short posterior flap as advised.
In amputating through the calf on the same principle, the operation is
similar, except that, for reasons before discussed,? the anterior flap need not
be longer than two-thirds of the diameter of the limb; but, to compensate
* See Medical Times and Gazette, July 6, 1861. = See Paste
ON AMPUTATION 409
for its diminution, the posterior flap must be made at least half as long as the
anterior, by carrying the knife round the back of the limb at an angle of forty-
five degrees through the integuments, and dissecting them up to the level of
the upper end of the inner part of the incision, before cutting towards the bones,
so as to get rid of the heavy and contractile mass of the sural muscles.
The old flap operation is still employed in the calf by many surgeons, being
very readily accomplished by drawing the knife in a segment of a circle across
the front of the leg from one bone to the other, transfixing behind them, and
cutting first downwards and then gradually outwards, next dissecting up the
anterior flap of integument, and clearing and dividing the bones at the level
of its base. But it is, as we have seen,’a most undesirable proceeding, on account
of the bulk of the muscular mass from the calf turned up to cover the ends of
the bones. Mr. Spence met this objection by shaving off a considerable portion
from the face of the posterior flap after forming it. But though this was
undoubtedly a great improvement, it could not give to the operation the advan-
tages of the method by longer anterior flap.
When there is not enough sound integument to admit of the latter method,
the modified circular operation of Mr. Syme? proves highly valuable, enabling
us to form out of the smallest amount of materials a short stump, which is
preferable to any that can result from operating higher up in the limb, the
patient either retaining the use of the joint or resting his weight with great
security and comfort upon the bent knee.
The great merits of Mr. Carden’s amputation through the condyles of the
femur have been already fully discussed.* I cannot but agree with him that the
patella should always be removed. In cases of injury it may seem a tempting
thing to leave it, sawing off its articular surface, that it may unite with the
divided end of the femur ; but having tried this plan before Mr. Carden published,
I have found that while it may result in an admirable stump, it is sometimes
attended with serious inconvenience, from the patella being tilted up from
its proper position by the action of the quadriceps extensor. Besides this,
the presence of the patella interferes with the adequacy of the covering for
the end of the femur, and makes it needful to borrow more integument from
the front of the leg than is otherwise requisite. And as regards the ultimate
result, when the sawn extremity of the femur has been rounded off by ossific
deposit, it proves little, if at all, inferior to the patella for bearing the weight
of the body. The only objection to Carden’s operation, as described by him,*
is the occasional occurrence of more or less sloughing of the long anterior flap
of skin, in spite of faultless operating. It is plain that the risk of sloughing
1 See p. 385. * Ibid. > See p. 387. * Ibid.
LISTER II Ee
410 ON) AMPUTATION
would be diminished if the flap could be made shorter by not carrying the horns
of the incision by which it is formed so high up the limb ; and on making experi-
ments on the dead body several years ago, to ascertain to what extent this could
be done without disadvantage, I found that it is by no means difficult, when the
parts are in their natural condition, to accomplish the operation without making
any anterior flap at all, the integuments in front being divided transversely
at the level of the lower end of Mr. Carden’s flap. I also found it advantageous
to form a short posterior skin-flap, both for the sake of coaptation of the cuta-
neous margins without puckering, and as a useful addition to the covering for
the end of the stump.
With this modification, the operation is performed as follows. The surgeon
first cuts transversely across the front of thé limb from side to side at the level
of the anterior tuberosity of the tibia, and joins the horns of this incision pos-
teriorly by carrying the knife at an angle of forty-five degrees to the axis of the
leg through the skin and fat. The limb being elevated, he dissects up the
posterior skin-flap, and then proceeds to raise the ring of integument as in a
circular operation, taking due care to avoid scoring the subcutaneous tissue ;
and, dividing the hamstrings as soon as they are exposed, and bending the knee,
he finds no difficulty in exposing the upper border of the patella. He then
sinks his knife through the insertion of the quadriceps extensor, and having
cleared the bone immediately above the articular cartilage and holding the limb
horizontal, he applies the saw vertically and at the same time transversely to
the axis of the limb (not of the bone), so as to ensure a horizontal surface for the
patient to rest on. The popliteal artery and vein are then secured, and any
articular or other small branches that may require it.
When the soft parts are thickened and condensed by inflammation, the
integuments cannot well be reflected above the patella with such incisions of
the skin. But the difficulty may be got over by cutting into the joint as soon
as the ligamentum patellae is exposed, and at once removing the leg by dividing
the ligaments and hamstrings ; after which the soft parts can be retracted from
the femur sufficiently to permit the application of the saw. The arteries having
then been secured, the patella is dissected out at leisure.
As thus performed, Carden’s operation takes a little more time and pains
than when the integument is divided in the form of an anterior flap ; but these
are well rewarded by the ample covering for the bone, the small external wound,
and the perfect security against sloughing.
Some surgeons speak highly of amputation through the knee, leaving the
articular portion of the femur and the patella, a covering being provided by
forming a large anterior and short posterior skin-flap from the leg, the result
ON AMPUTATION AII
being that the patient rests his weight upon the broad rounded end of the bone
while the patella is drawn up by the quadriceps to occupy the hollow between
the condyles in front.". There can hardly, I think, be two opinions as to the
superiority of Carden’s method to this procedure for carious disease of the
knee-joint ; and in cases of injury, when the integuments are sound as far as
five inches below the patella, which is the length of the long anterior flap accord-
ing to the method hitherto recommended,’ a satisfactory though very short
stump may be made below the knee. But from my experience with Carden’s
operation I feel sure that the amputation through the knee may be much
improved by dividing the integument in the circular fashion, slightly modified
to permit neat adjustment of the cutaneous margins, in which case it would
not only be freed from the risk of partial sloughing of the anterior flap which is
admitted by its advocates,’® but, the posterior integument being made to take
a larger share in forming the covering, it would not be needful to go so far down
the limb in front, and thus the operation would become available for cases of
injury reaching too high in the limb to permit amputation below the knee.
And in order to ensure complete adequacy of the covering, the saw might be
carried through the middle of the articular end of the femur so as to flatten
it without interfering with its breadth, and thus in all probability improve
rather than impair the fitness of the end of the stump for bearing the weight
of the body. On this matter, however, I cannot as yet speak from personal
GXPerience.
In amputation of the thigh, if we except cases in which the soft parts are
affected at one side only, where a covering may be advantageously provided
from the sound side, the flaps should always be antero-posterior, because, the
flexor muscles being no longer counteracted by the weight of the limb, the bone
tends to become tilted forwards, so that its extremity would be apt to show
itself in the anterior angle of lateral flaps.
In the lower half of the thigh, the method by longer anterior flap, on the
principles before considered,* will be found easy of execution and excellent in
results. Two straight incisions are made through the skin and fat along the
lateral aspects of the limb, parallel to its anterior surface, and equal in length
to two-thirds of its diameter, and their inferior extremities are connected in
front by a straight transverse cut, curved upwards near its ends to join the
longitudinal ones, so as to shape out a moderately long rectangular flap with
rounded angles, if we may so speak. The knife is then passed round the back
* See especially a paper on Amputation at the Knee-joint, by Mr. Pollock, Medico-Chirurgical
Transactions, 1870.
* See Mr. Pollock, ibid. * Tbid. ‘See p. 388.
Be 2
412 ON AMPUTATION
of the thigh at an angle of forty-five degrees to its axis, marking out a short
posterior skin-flap, which is at once dissected up, the limb being well elevated
by an assistant. The anterior flap is next raised so as to contain a moderate
amount of muscle, and the soft parts being well retracted, the knife is swept
circularly through the muscles, so as to expose the bone for the application
of the saw about two inches above the angle of union of the flaps.
The incisions should always be made as far down in the limb as the state
of the soft parts permits ; and the skin over the patella, if available, will be
employed with great advantage as part of the anterior flap.
For restraining haemorrhage the elastic tourniquet must be applied as
high as possible in the thigh, and if its constriction is found to interfere with
the due retraction of the soft parts, it is best to saw the bone in the first instance
where it is easily reached, and, after securing the vessels and removing the
tourniquet, expose the bone at the requisite level, and saw off an additional
portion, held steady with a pair of strong forceps.
When digital compression is resorted to, the hands should grasp as much
of the circumference of the limb as possible, while the thumbs are placed one
above the other over the vessel, as it lies on the pelvis, midway between the
symphysis pubis and the iliac spine.
Even in the upper part of the thigh, although the object of having a stump
capable of bearing weight upon its extremity is no longer to be considered, the
operation above described will be found to yield better results than that by
transfixion, by avoiding the redundancy of muscle which is the great defect
of the latter method. Nor need this plan involve greater loss of blood. For
the posterior flap, being only cutaneous, can be raised without material bleeding ;
and the anterior flap, after being shaped by carrying the knife through the skin
and fat, may be completed by transfixion, while comparatively little retraction
of the soft parts is required, in consequence of the short-cut muscles having
little tendency to cause protrusion of the bone. Moreover, all bleeding during the
performance of the operation may be effectually prevented by the elastic band
applied in the manner to be described in connexion with the next amputation.
Amputation at the hip-joint has of late years been divested of much of
the danger that formerly attended it ; so that it now ranks among the well-
established operations of surgery.
What may be termed the classical method is to form a large anterior flap
by transfixion, disarticulate, and cut a short posterior flap, also from within
outwards. The thigh being somewhat fixed, to relax the soft parts of the front
of the limb, the point of a knife with a blade fully a foot in length is entered
midway between the anterior-superior spinous process of the ilium and the
ON AMPUTATION 413
great trochanter, supposing the left side operated on, and passed in front of the
bone till it emerges near the tuberosity of the ischium, or in the opposite direc-
tion if the right limb be concerned. The knife is then carried longitudinally
with a rapid sawing movement, followed by the fingers of one hand of an assistant,
which are introduced into the wound so as to compress the femoral artery
securely between them and the thumb, previously placed over it in the groin,
his other hand being employed to lift up the large anterior flap as soon as it is
completed. The limb being now extended and abducted, the surgeon opens
the capsule of the joint by cutting firmly upon the head of the bone; and as
this starts from its socket, he divides the round ligament and the posterior
part of the capsule ; and lastly, the thigh having been adducted, to draw the
trochanter down out of the way of the knife, he completes the severance of
the limb by cutting downwards and backwards through the muscular mass
at the back of the thigh.
Attention is now at once directed to the bleeding vessels of the posterior
flap, fed by the internal iliac, which are covered in the first instance with a
folded cloth, or, what is better, by the tips of the fingers of an assistant ; and
when they have been tied the femoral trunk and any of its branches which
may require it are secured in the anterior flap.
But though I have described this mode of operating, captivating as it is
by its brilliant swiftness of performance, I do not desire to recommend it. Many
years ago I was much impressed with a circumstance that I witnessed in the
practice of one of my colleagues in Glasgow. He amputated below the tro-
chanters by antero-posterior flaps for malignant sarcoma of the lower part
of the femur; but the part of the bone removed being examined after it had
been sawn longitudinally while the vessels were being secured, the disease was
found to extend up to the part where it had been divided in the amputation.
The surgeon therefore seized the remainder of the femur with powerful forceps
and dissected it out from its socket. This was done with great facility and with
scarcely any loss of blood; and it occurred to me that, if the same procedure
were adopted when it was intended from the first to disarticulate, shock, which
is one of the great dangers of amputation at the hip-joint, would surely be
greatly diminished ; for we could not suppose that the powerful impression
produced upon the nervous system by that operation performed in the usual
way could be due either to the removal of the head of the bone or to the mere
extent of the cut surface as such. The correctness of this view has been since
strikingly demonstrated by the practice of Mr. Furneaux Jordan, of Birmingham,
who, in cases suitable for such a procedure, first divides the soft parts circularly
low down in the thigh, and then dissects out the bone from among the muscles
414 ON AMPUTATION
and from the acetabulum through a long incision on the outer aspect of the
limb, where the soft parts are comparatively thin and the blood-vessels incon-
siderable ; a long boneless stump being the result. Now such an operation
involves both disarticulation and the formation of an exceedingly extensive
wound ; yet Mr. Jordan’s anticipations of increased safety of this method as
compared with the old one seem to have been fully realized. Ever since the
Glasgow experience to which I have referred, I have myself proceeded on the
principle which it suggested ; and while it does not seem to me necessary to
push it to the extreme degree advocated by Mr. Jordan, I would advise the
following as the method to be generally adopted.
Supposing the right limb operated on, the knife is entered at the posterior
part of the great trochanter and carried down longitudinally for about eight
inches (if the patient be an adult male), and then drawn across the limb in front
and behind through skin and fat, in the form of two crescentic incisions which
meet at the inner side of the limb at a point an inch or two lower down than the
extremity of the outer longitudinal cut. The semilunar flaps mapped out by
the crescentic incisions are then dissected up as in a modified circular operation,
the integument being raised about two inches higher than their angle of union
at the inner side of the thigh ; after which the muscles are divided where they
are exposed and the head of the bone dissected out.
Such a mode of operating, besides the diminished danger from shock, has
the great advantage of making truly aseptic treatment easy, instead of almost
impossible, as it is when the copious sero-sanguineous discharge which takes
place from so large a wound is poured out within a very few inches of the anus,
which is the case after the ordinary operation, with the dependent angle of the
wound close to the tuberosity of the ischium. After the operation which
I have advised, the inner end of the wound having been closely stitched and
drainage-tubes introduced at its outer part, there is sufficient space for an
effectual antiseptic dressing, which will often be a matter of life and death where
so large an extent of irritable and absorbent surface is concerned.
The longer time occupied by the operation is of no consequence now that
we have the means of dealing efficiently with the once dreaded haemorrhage.
For this purpose I advised in former editions of this work the use of the aortic
tourniquet. This instrument, however, has two defects. In the first place,
when the aorta deviates to any considerable extent from its normal median
or nearly median position, the tourniquet is somewhat difficult of adjustment,
and instead of retaining its position by the clamping action of the screw which
presses down the pad, it tends to slip to one side on the rounded body of the
lumbar vertebra, and must be held in place by a very careful and steady assistant.
ON AMPUTATION 415
And, in the second place, an inexperienced or nervous surgeon may be tempted
to screw down the rigid instrument with needless violence and damage the
intestine by so doing.
Mr. Davy, of the Westminster Hospital, has suggested a very ingenious
mode of compressing the common iliac artery by introducing into the rectum
one end of a smooth wooden cylinder two feet in length and about an inch in
diameter passed in sufficiently far to permit it to be pressed down upon the vessel
on the brim of the true pelvis when the other end or handle of the instrument
is carried to the thigh of the opposite side, and then raised so that the rod may
act as a lever for which the anus serves as a fulcrum.! In most cases in which
Davy’s lever has been employed it has answered to admiration.” But it is
intelligible that in case of a short mesorectum it might be impossible without
undue force to effect compression of the iliac trunk on the right side; and of
course if the coats of the rectum were unsound, the instrument would be wholly
inapplicable. Accordingly, I lately heard of a case in which a gentleman
specially conversant with the use of the lever failed to bring it into effective
action; and another case has been mentioned to me where death resulted
from mischief done by the end of the rod working in the dark.
Hence I believe it to be wiser to adopt here also the principle of Esmarch’s
elastic compression. It may be applied either to the aorta or to the extreme
upper part of the limb. For the aorta a pad of sufficient size, such as a pin-
cushion, adjusted over the vessel about the level of the iliac crests, is pressed
down by elastic bands, which, however, ought not to encircle the body directly
and so cause inconvenient constriction of the waist, but should be connected
with the ends of a rigid object placed transversely beneath the back and extend-
ing laterally sufficiently far to protect the sides of the body from compression.
A narrow piece of board with two lateral notches at each end would answer
the purpose quite well for an emergency as a substitute for the curved piece
of stout iron with rings or hooks at the ends recommended by Esmarch.
When the elastic band is applied to the imb for amputation at the hip-
joint, special arrangements must be adopted to keep it well out of the way of
the knife, and also to prevent it from slipping down and becoming useless when
the support of the head and neck of the bone is withdrawn by disarticulation.
The following method will be found to answer perfectly. An elastic band
having been provided sufficiently strong to require the full force of the surgeon
to stretch it to twice its length,’ and long enough to encircle the upper part of
' See British Medical Journal, May 18, 1878.
* See Mr. Pearce Gould, Tvansactions of Clinical Society of London, 1879.
* About three of the ordinary rods of red caoutchouc, placed side by side and tied together at their
ends, will be found to answer the purpose for an adult.
416 ON AMPUTATION
the limb when in the relaxed condition, and with tapes securely connected
with its ends, is placed with one end of the elastic part under the sacrum, while
the tape of that end is brought round the pelvis between the crest of the ilium
and the great trochanter of the side opposite to that to be operated on, and
held perfectly firmly in the vertical position by an assistant. The surgeon then,
standing on the side for operation, puts the band fully on the stretch in a direction
transverse to the body and brings it up into the vertical position immediately
below the iliac crest. Holding it inhis left hand (if the right limb is concerned),
he next passes his right hand round behind the limb, which has been previously
placed in the vertical position to expel its blood, and, changing hands, encircles
the thigh as near to the perineum as possible, the scrotum being held well to
the other side by an assistant. The surgeon’s end of the elastic band being
now over the groin, he takes the other tape from his assistant and ties the two
tapes together in a reef-bow over the sound side. Another point requires
attention. Two pieces of bandage, each about two feet in length, are placed
longitudinally upon the skin before the elastic band is applied, one of them over
the groin, the other well behind the great trochanter ; the middle of each piece
of bandage being in the situation where the elastic band is to go. And when
the elastic band has been applied, the lower end of each of these pieces of bandage
is drawn up so as to convert them into two loops by means of which, in the hands
of a steady assistant, the elastic tourniquet is kept drawn well up both at
Poupart’s ligament and behind the trochanter. If this arrangement is well
carried out, the whole operation, including disarticulation, may be done un-
interruptedly. Nevertheless, I think it prudent to retain the resistance of the
head and neck of the femur so long as the tourniquet is in operation, by sawing
through the bone below the trochanters, and at once securing all the vessels
that show themselves on the cut surfaces. The tourniquet is then removed
while an assistant compresses the femoral at the groin: and when any branches
still requiring attention have been tied, the remainder of the bone is seized
with strong forceps and dissected out. With the incisions which have been
recommended this will be found a matter of the utmost facility and attended
with little if any haemorrhage.!
* The article on Amputation was first published in the rst edit. of Holmes’s System of Surgery,
vol. iii, 1862. It afterwards appeared in the 2nd edit., vol. v, 1871, and in the 3rd edit., vol. iii, 1883.
In its later appearances, while retaining its original features, it was altered in various details in
accordance with the progress of knowledge.
ON EXCISION OF THE WRIST FOR CARIES
[Lancet, 1865, vol. i, pp. 308, 335, 362.]
To save a human hand from amputation, and restore its usefulness, is
an object well worthy of any labour involved in it. When caries affects the
shoulder or the elbow, the limb is preserved by excision of the diseased joint,
and the brilliant success of these operations naturally suggested a similar pro-
cedure for the wrist. The first attempt of this kind appears to have been made
as early as the close of the last century by the younger Moreau, who, however,
gives but few details of his case. In 1839, a German surgeon, named Dietz,
is said to have removed all the carpal bones, together with the ends of the radius
and ulna, on account of caries. But as such an operation must necessarily
have been very painful and protracted, we cannot wonder that it was not
repeated till after the introduction of chloroform, when, in 1849, Heyfelder,
of Erlangen, excised the wrist-joint for disease, and he has been followed by
many surgeons, both British and foreign, who have adopted various methods
of effecting their object.
The results of this practice, however, have not proved encouraging. For
although several instances of success have been put on record, it is generally
admitted that these are quite exceptional,? and amputation is now again con-
sidered by most surgeons the appropriate treatment for caries of the carpus.
About two years ago a more hopeful view of the subject was suggested
to me by a case of injury under my care in the infirmary. The patient was
a young man, seventeen years of age, who had fallen about fifty feet down the
shaft of a coal-mine, and, besides fracture of the left thigh, had sustained a
compound dislocation of the wrist of the same side, the articular ends of the
radius and ulna protruding anteriorly for about an inch and a half through
a large irregular wound. I sawed off the exposed portions of the bones, and
placed the limb on a splint ; and, commencing passive movement of the fingers
early, and maintaining it perseveringly, I had the satisfaction of seeing him,
at the end of five months, with a hand nearly as supple and strong as the other,
the chief difference between them being that the wrist of the injured side was
rather more slender than the sound one.
This case appeared to me to throw light upon excision of the wrist for
disease. In the first place, it was clear that no operation, intentionally performed,
* See O. Heyfelder, Operationslehre und Statistik der Resectionen, p. 262.
* See Erichsen’s Sctence and Art of Surgery, 4th edit., 1864, p. 768. Holmes’s System of Surgery,
vol. lili, 1862, p. 812.
418 ON EXCISION OF THE WRIST FOR CARIES
would do such violence to the tendons as must have been inflicted in that acci-
dent, both on the flexors through which the ends of the bones were so rudely
thrust and on the extensors wrenched out of their sheaths in spite of the secure
connexions of the annular ligament. Hence the favourable issue of this case
indicated that the tendons might be very freely dealt with in gaining access
to the carious bones without inducing stiffness of the fingers, provided the after-
treatment were rightly conducted.
And in the second place, the fact that a useful hand had been retained after
the loss of so large a portion of the bones, suggested that the same happy result
might follow removal of the whole articular apparatus of the wrist ; that is to
say, excision of all the carpal bones, together with the ends of the radius and
ulna, and the bases of all the five metacarpal bones.
If this were done, recurrence of the disease, the grand cause of disappoint-
ment in excision of the wrist, would, as I hoped, be avoided ; and the operation
would be placed on a par with excision of the elbow, which, if properly per-
formed, may be relied on with almost absolute security for complete extirpation
of the caries. I have long believed that the reason of the remarkable success
attained in this respect by excision of the elbow is that the surgeon (when
operating in the manner to which I allude) takes away in all cases, however
limited the disease may seem, the entire surface covered with cartilage. For
it is in the cartilage that caries commonly takes its origin, and even parts
of it which may appear sound in a carious joint seem apt to be affected in an
insidious, incipient degree, and if left behind may lead to recurrence of the
complaint. But, in excising the wrist, all that has hitherto been aimed at
has been to take away such portions of the bones as are found to present un-
healthy characters, leaving behind more or less of the articular surfaces, which,
from the forearm to the metacarpus, may be viewed with reference to caries
as forming a single complicated joint, though subdivided in health into three
synovial sacs. On the other hand, if the whole of the structures thus liable
to morbid action were cleared out, there seemed good reason to hope that success
in excision of the wrist for caries might become the rule instead of the exception.
A few months later two cases of caries of the wrist presented themselves
for treatment, and, after some experiments upon the dead body, I resolved
to test the new principle upon them, and operated upon both on the 16th of
April, 1863. Since that time the practice of our large infirmary has afforded
me frequent similar opportunities, which have enabled me gradually to improve
both the operative procedure and subsequent management, and also to judge
fairly of the ultimate results. These having proved fully equal to my theoretical
anticipations, I now feel called upon to bring the subject under the notice of
ON EXCISION OF THE WRIST FOR CARIES 419
my professional brethren ; and first I will give shortly some illustrative cases,
reserving meanwhile the details of the treatment.
CASE 1.—Elizabeth M‘K——, a millworker, aged forty, in good general
health, was admitted on the 27th of October, 1862, on account of suppuration
of the right carpus, resulting from the hand having been violently pinched in
a door. Pus was discharged from openings at the back of the wrist, and the
carpal bones were felt to grate upon one another on manipulation.
The disease being of traumatic origin, I hoped it might subside if the limb
were kept at rest upon a splint, and free exit were provided for the discharge.
This treatment was persevered with for upwards of five months, but proved
unavailing ; and she also continued to suffer considerable pain. Accordingly,
on the 16th of April, 1863, I removed the carpus, and at the same time took
off so much of the bones of the forearm and of the five metacarpal bones that
the interval between them where they were divided measured two inches and
a half. The bones of the carpus and the metacarpal bones of all the fingers
proved to be extensively eroded by caries.
Seven weeks after the operation the limb was almost healed and promised
a most satisfactory result, when, being an ignorant woman, and mistaking our
efforts to maintain the flexibility of the fingers for attempts to break them
she ran away from the hospital, and did not show herself again for nearly five
months, during which time she had kept the fingers extended and motionless
upon the splint she took out with her. Consequently they were almost abso-
lutely rigid, and the movements of the thumb were also extremely limited,
so that the hand was nearly useless, while, from the position in which it had
been habitually held, it had acquired some tendency to droop towards the ulnar
side. It was, however, soundly healed; and, through repeated forcible move-
ment under chloroform to break down the adhesions of the tendons, and the
use of a leather splint to support the palm and ulnar border of the hand without
interfering with the thumb or fingers, it improved remarkably, and when she
left the hospital in April 1864 she could use it for wringing a cloth or knitting
a stocking. The improvement has since been progressive. In August it was
found that without the splint she could readily lift a kettle of water weighing
six pounds, implying a most satisfactory command of the muscles over the newly
formed articulation. At first I had aimed at anchylosis of the wrist, but was
now much better pleased to see that it retained the power of flexion and extension,
eversion and inversion, pronation and supination. Even now (March 1865)
the limb is still increasing in strength, in proof of which she lately raised with
outstretched hand a pail of coals weighing 16} pounds. She has for the last
420 ON EXCISION OF THE WRIST FOR CARIES
six weeks entirely discarded the support, having found the hand exactly as
strong without it. The new wrist is now as firmly knit as the sound one, but
more slender in consequence of the radius and ulna having been so freely resected.
CASE 2.—Margaret W——,, aged fourteen, a sewing-machine worker, was ad-
mitted on the 2oth of March, 1863, when she stated that a swelling had appeared
five months previously on the back of her right hand, which, however, remained
free from pain till within about three weeks, when suppuration occurred. An
incision was made by her medical attendant, but this failed to relieve her ; and
when she came into the infirmary she was still suffering severely, while there
was also considerable swelling of the hand.
ATG it.
The limb was placed on a splint and poulticed, but additional abscesses formed
and opened, and at length the probe distinctly indicated caries of the carpus.
On the 23rd of May I excised the parts represented in Fig. 1. The carpus
was chiefly affected by the disease, but the metacarpal bones of all the fingers
were implicated, and the radius was anchylosed to the scaphoid and semilunar.
Constant attention being subsequently paid to supporting the wrist and bending
the fingers, she progressed steadily, though slowly. Thus seven weeks after
the operation, the hand no longer drooped when the arm was extended hori-
zontally ; three months and a half later she could take up a roll of bandage
between the finger and thumb; and when three months more had elapsed
she knitted part of a stocking without using any splint. About this time, as
she had never learned to write, the nurse of the ward taught her the art, which,
being a clever girl, she soon learned; and half a year afterwards I received
from her a letter, well written with the affected hand, requesting a certificate
of soundness for the satisfaction of her old employer, who was about to re-
ON EXCISION OF THE WRIST FOR CARIES 421
engage her. In August 1864 I saw her again. She was then employed at
the sewing-machine, earning ten shillings a week, with the expectation of eleven
shillings before long, as she was considered one of the best hands at the work.
She still wore a leather support for the palm, but without it could lift a heavy
weight with the arm horizontal. She stated that there had been no discharge
from the hand for the last two months ; and that the only way in which she could
convince her friends of the nature of the operation she had undergone was by
showing to them her two arms extended side by side, the affected limb measuring
two inches less than the other from the elbow to the finger-tips. Lastly, in
December 1864, I learned that the hand was still constantly increasing in
strength, and that she was on her full wages.
CASE 3.—William C——, aged eighteen, a clerk, was admitted on the r4th
of January, 1864. Two years previously I amputated the great toe of his
right foot on account of strumous disease. The wound was slow in healing, and
in walking with a stick he thinks he over-exerted the right wrist, which became
swollen and disabled, though for a long time free from pain. The treatment
employed failed to arrest the disease, and at length suppuration occurred ; and
a probe introduced through one of the openings by which the matter escaped
passed down to carious disease in the carpus. The hand had now been useless
for a twelvemonth, and I recommended him to submit to incision, for which
purpose he came into the infirmary.
On the 16th of January I removed the carpus, together with the articular
ends of the adjacent bones. His progress afterwards was satisfactory. Within
seven weeks of the operation he could bend the fingers, and raise the metacarpus
by muscular action at the same time ; and five weeks later he left the hospital,
able to pick up light objects with the unsupported hand, and to execute to some
extent all the natural movements of the wrist-joint. In August, after four
months more had elapsed, the actions of the wrist were much more free, and
the new joint was so secure that without any splint he could support a kettle
of water weighing six pounds and a half upon the radial border of the hand
with the arm extended horizontally, and easily lifted a chair with the arm
vertical. He bent the fingers imperfectly at the knuckles, but moved their
other joints and both those of the thumb very freely, and he could hold a pen
so as to write with considerable steadiness. In September all discharge finally
ceased. The hand has since remained perfectly sound ; and when I saw him in
December 1864 there was nothing in its appearance to attract attention. He
was engaged in a situation where little writing was required, but the hand was
becoming more and more serviceable for that purpose. Its grasp also was con-
422 ON EXCISION OF THE WRIST FOR CARIES
siderably stronger, and he used it occasionally to work the bellows of a forge.
He still derived benefit from a palmar support with which he had been furnished,
but he had gone without it for a week at a time, and promised soon to be entirely
independent of it.
CASE 4.—Helen M , aged fourteen, a schoolgirl, admitted on the 19th
of February, 1864, attributed the disease, which had appeared seven months
before in her left wrist, to a violent squeeze experienced at that time. Three
months after the accident it suppurated, and was opened on the dorsal aspect
by a medical man ; but its condition became rapidly aggravated, and at length
her parents sent her to the infirmary to have the hand amputated. That this
was the only feasible treatment was certainly a most natural conclusion from
the appearance presented by the affected part. The hand was enormously
swollen both on the palmar and dorsal aspects, and drooped helplessly from
ligamentous relaxation; while the fingers were almost fixed in a semiflexed
position. There were several sinuses on the back of the hand, and in front of
the wrist a deep ragged grey sore as large as a half-crown, and another smaller
ulcer on the palm. Her general health at the same time was much reduced.
But most unpromising as the case appeared, I determined to give the hand
a chance, and at the same time test fully the capabilities of the new method.
On the 5th of March I removed the carious mass, when the metacarpal bone
of the middle finger proved to be so extensively affected that it was necessary
to drill it with the gouge into a mere tube, which must have reached to near
the knuckle, as a portion of the cartilage in connexion with the epiphysis was
removed by the instrument.
The result turned out satisfactory, and she left the hospital on the 30th of
July, with the sores and sinuses almost healed, and able to move all the fingers
freely, and also, at an earlier stage than in any previous case, to raise the knuckles
above the level of the forearm by muscular effort. In October she could support
a kettle of water on the radial border of the hand, and her general health was
completely re-established. In the middle of December she could take up a quart
bottle full of water, holding it by the neck between the forefinger and thumb.
She was herself disposed to dispense with the palmar support, but was recom-
mended to continue it, so as to favour as much as possible the rapid increase
of strength and usefulness. There had been no discharge for the last month,
except a little moisture on the removal of a scab ; and the part once so greatly
deformed was nearly natural in appearance. When I last saw her (March
1865), she told me she was learning to work at a sewing-machine, and found
her hand thoroughly useful for the purpose.
ON EXCISION OF THE WRIST FOR CARIES 423
it
CASE 5.—Thomas M——, aged twenty-one, a miner, was admitted on
the 8th of July, 1864. About six months before, when suffering from small-
pox, he was seized with inflammation in the right tibia and the left carpus,
resulting in necrosis of the former and caries of the latter. When he came
into the hospital the back of the wrist was swollen, and presented two sinuses
through which a probe could be passed down to the diseased bone. The hand
was extremely feeble, and drooped when the arm was extended horizontally.
It was very painful, interfering seriously with his night’s rest, and his general
health was otherwise much deranged, his pulse being 135, and his appetite
impaired, while he was constantly bathed in perspiration.
On the 16th of July I extracted some exfoliations from the affected tibia,
and also removed from the wrist the parts represented in Fig. 2. A carious
BiG:
cavity occupied the place of the semilunar bone, and the adjacent part of the
cuneiform was excavated. The other carpal bones, except the trapezium,
were anchylosed into one mass. Two days after these operations his pulse
had fallen eleven beats, and after two days more he was recovering his appetite,
and had lost his perspirations, while his former anxious expression was exchanged
for that of cheerfulness. The improvement in his general health continued,
and the hand made most satisfactory progress. Six weeks and six days after
the excision it was soundly healed, and the swelling had entirely disappeared.
He could move all the joints of all the fingers and both those of the thumb, and
performed to some extent all the natural actions of the wrist. A fortnight later
he stood the test of lifting a weight of six pounds and a half with the unsup-
ported hand in the horizontal position of the forearm. In November, four
months after the operation, the movements had so greatly increased in freedom
and firmness, and the hand had so thoroughly natural an appearance, that it
was with difficulty some of my medical friends could be persuaded that the
424 ON EXCISION OF THE WRIST FOR CARIES
carpus had been removed at all, more especially as a growth of new bone from the
radius presented considerable resemblance to the prominence of the os magnum.
On the 13th of February he entirely discarded the leather support, which for
some time he had only worn at night as a safeguard, and now (March) his hand
has a powerful grasp, and is in all respects nearly, if not quite, as useful as ever.’
CASE 6.—Mary Ann L , aged nineteen, a millworker, was admitted on
the 22nd of October, 1864. Her case differed from any of the preceding, in
being extremely acute. Ten days before her admission, pain came on at night
in the right wrist without any assignable cause, and increased from day to day
till it became agonizing. When I first saw her the whole hand and the neigh-
bouring part of the forearm were greatly swollen and fiery red, and contained
a considerable amount of pus, which I evacuated by very free incisions. This
relieved her only temporarily ; and, when she had been in the hospital twelve
days, it was obvious that some very decided treatment was called for. During
the whole of that time she had taken nothing but water, and had slept very
little, so that her flesh and strength were rapidly diminishing; and, on
manipulation of the wrist, it felt like a bag of loose grating bones.
Though I feared that the tendons might have sloughed from vicinity to
such intense inflammation, and that the case was likely to do little credit to the
operation, I felt it my duty to remove the carpus with the neighbouring articular
surfaces, which I did on the 2nd of November. The carpal bones were found
almost entirely detached from one another, and all of them, as well as those
of the forearm and the metacarpal bones of the fingers, were eroded by ulceration.
The tissues beneath the extensor tendons were so disorganized as to break
down readily under the finger; but, happily, the tendons themselves had not
suffered seriously, as was proved by the event.
The second night after the operation she slept without an opiate, and on
the following day took some beef-tea ; and from this time forward she regained
her strength and flesh as quickly as she had previously been losing them. The
cavity produced by excision of the bones consolidated with great rapidity.
After three weeks she could pick up a roll of bandage with the finger and thumb
of the unsupported hand ; and on the 28th of December (eight weeks from the
operation) cicatrization was complete. The wrist was then already firmer than
in any previous case at that period, so that the base of the hand could not be
moved from side to side at all, though she could herself perform flexion and exten-
sion, pronation and supination, with increasing freedom. She could also use
every joint of the fingers and thumb, which were growing more and more supple
as they gradually lost the thickening of tissue which the acute inflammation
* For a further notice of this case see p. 199.
ON EXCISION OF THE WRIST FOR CARIES 425
had induced. At the present time (March 1865), though she wears a leather
support as a measure of precaution, she can write a fair hand without it, and also
employs herself frequently with knitting or crochet-work.
In reading the above cases it will have been observed that the later ones
show a superiority over the earlier, both in their rate of progress and in their
results. This is due principally to successive improvements which experience
has suggested in the mode of treatment.
In the earlier cases I made two longitudinal incisions, both on the dorsal
aspect of the limb, one at the radial,
the other at the ulnar side, sacrificing
in the radial incision the extensor of
the second joint of the thumb ; then
divided the extensors of the carpus
opposite the wrist-joint ; and having
detached the tendons sufficiently from
the radius and ulna, removed the
articular ends of those bones by means
of a small saw and cutting-forceps
applied transversely. Next, after
separating the tendons from the car-
pus, I sawed or clipped through the
metacarpal bones of the fingers, so as
to extract their extremities together
with the greater part of the carpus ina
single piece, dissecting out afterwards
any articular portions that remained.
This method proved far from _per-
Fic. 3.—A A, deep palmar arch; B, trapezium ;
C, articular surface of the ulna, over which
fect, both in the way in which the ed ee i
bones were dealt with and in the mode of gaining access to them.
As regards the bones, it was objectionable in two ways. _ In the first place,
the bones being divided transversely so as to include all the cartilage-covered
surfaces, a needlessly large amount was removed both from the radius and ulna
and from the metacarpus. Ina case of disease apparently limited to the carpus,
the essential principle of the operation would be carried out by merely taking
away what is represented by the unshaded parts of the accompanying diagram
(Fig. 3), taken from a faithful sketch of the bones of the right wrist, the thick
lines indicating the extent of the articular surfaces. But the original method
sacrificed in all cases at least as much bone as is included between the dotted
LISTER II Ff
426 ON EXCISION OF THE WRIST FOR CARES
lines of the same diagram, and it will be readily understood that the greater
loss both of length and breadth of the bones must have interfered seriously with
the process of consolidation, and impaired the ultimate strength of the hand.
This point may be further illustrated by comparing the sketches in Figs. 1 and 2,
of which the former exhibits the parts removed according to the first method
in Case 2, and the latter the portions excised on an improved plan in Case 5,
which was very similar as regards the extent of the disease.
But a greater objection to the original procedure lay in the fact that, the
bones being divided in the dark, there was serious risk of leaving behind some
portions of the disease ; for it is, of course, impossible to know beforehand the
precise extent of the caries, and when the bones have been confused by operative
interference, it is somewhat difficult to judge accurately of their condition.
In order to attain completely the twofold object of taking away all the
disease, and leaving behind all bone that may be relied upon as sound, it is
desirable that both the radius and ulna and the metacarpal bones should be
presented untouched for examination; and in my later cases this condition
has been fulfilled in a thoroughly satisfactory manner by removing the carpus
in the first instance, when the free space so afforded permitted me to deal
methodically and surely with the other bones.
The soft parts, too, were by no means in the best possible condition after
the original operation. In exposing the ends of the bones, and especially the
radius, for the application of the saw or pliers, the tendons were separated
from their sheaths to an extent which the preliminary removal of the carpus
' renders quite unnecessary. They consequently acquired a disposition to con-
tract adhesions to neighbouring parts, which occasioned a great deal of needless
trouble in the after-treatment.
Again, the division of the extensors of the carpus opposite to the wrist-
joint gave less power of raising the hand than was afterwards obtained by cutting
them long at their insertions into the metacarpus, and so imitating as nearly
as possible the natural arrangement. This point seemed deserving of con-
sideration when the progress of some of the cases had proved that those
muscles will regain command over the hand. The idea was first acted on in
Case 3, that of Wiliam C——, and the result in him and in all that have
followed him has shown that it is well worthy of attention.
I also found that by properly planning the radial incision it was quite
unnecessary to sacrifice the extensor secundi internodii pollicis, and in the more
recent cases the second joint of the thumb has commonly been moved with
perfect freedom, whereas in the earlier ones the first joint only was capable of
any material motion.
ON EXCISION OF THE WRIST FOR CARIES 427
Lastly, it appeared that to have both the incisions on the dorsal aspect
of the hmb was by no means the best arrangement ; for, while the radial incision
must necessarily be at the back of the hand, that on the ulnar side is advan-
tageously made towards the palm, where it gives the most ready access to the
palmar surface of the carpus, and avoids injury to the tendons of the extensor
carpi ulnaris and the extensor minimi digiti, while it affords a dependent opening
for the escape of discharges from the cavity.
The foregoing discussion of the defects of my first mode of operating will,
I trust, prevent other surgeons from going over the laborious ground of gradual
improvement over which I have travelled, while it will enable the reader to
appreciate the advantages of the method which I now venture to recommend.
The operation is performed in the following manner: Chloroform having
been administered, a tourniquet is placed upon the limb to prevent oozing of
blood, which would interfere with the careful scrutiny to which the bones must
be subjected. Before the operation is commenced, any adhesions of the tendons
are thoroughly broken down by freely moving all the articulations of the hand.
The radial incision is then made in the situation indicated by the thick line
(L L) in the accompanying diagram of the anatomy of the back of the hand
(Fig. 4). This incision is planned so as to avoid the radial artery, and also the
tendons of the extensor secundi internodii pollicis and indicator. It commences
above at the middle of the dorsal aspect of the radius, on a level with the styloid
process, this being as close to the angle where the tendons meet as it is safe to
go. Thence it is at first directed towards the inner side of the metacarpo-
phalangeal articulation of the thumb running parallel in this course to the
extensor secundi internodiu ; but on reaching the line of the radial border of
the second metacarpal bone it is carried downwards longitudinally for half the
length of the bone, the radial artery being thus avoided, as it lies somewhat
further to the outer side of the limb. These directions will be found to serve,
however much the parts may be obscured by inflammatory thickening. The
soft parts at the radial side of the incision are next detached from the bones
with the knife guided by the thumb-nail, so as to divide the tendon of the extensor
carpi radialis longior at its insertion into the base of the second metacarpal
bone, and raise it, along with that of the extensor carpi radialis brevior previously
cut across, and the extensor secundi internodii, while the radial artery is thrust
somewhat outwards. This prepares the way for the next step, which is the
separation of the trapezium from the rest of the carpus, by means of cutting
forceps applied in a line with the longitudinal part of the incision—a procedure
which, as experience shows, does not endanger the radial artery. The removal
of the trapezium is reserved till the rest of the carpus has been taken away,
Ff 2
428 ON EXCISION OF THE WRIST FOR CARIES
when it can be dissected out without any considerable difficulty ; whereas its
intimate relations with the radial artery and its secure connexions with neigh-
bouring parts would cause a great deal of trouble at an earlier stage of the
operation. The soft parts on the ulnar side of the incision are now dissected
up from the carpus as far as is convenient, the hand being bent back to relax
the extensor tendons of the fingers. The separation of these is, however, best
effected from the ulnar incision, which must be made very free. The knife is
=
ti
Fic. 4.—A, radialartery. B, tendon of extensor secundi inter-
nodii pollicis. C,indicator. D, extensor communis digitorum.
E, extensor minimi digiti. F, extensor primi internodii pollicis.
G, extensor ossis metacarpi pollicis. H, extensor carpi radialis
longior. J, extensor carpi radialis brevior. AK, extensor carpi
ulnaris. L L, line of the radial incision.
entered at least two inches above the end of the ulna, immediately anterior
to the bone, and is carried downwards between it and the flexor carpi ulnaris,
and on in a straight line as far as to the middle of the fifth metacarpal bone
at its palmar aspect. The dorsal lip of this incision is then raised, and the
tendon of the extensor carpi ulnaris is cut at its insertion into the fifth meta-
carpal bone, and is dissected up from its groove in the ulna, care being taken
to avoid isolating it from the integuments, which would endanger its vitality.
The extensors of the fingers are then readily separated from the carpus, and
the dorsal and internal lateral ligaments of the wrist-joint are divided; but
ON EXCISION OF THE WRIST FOR CARIES 429
the connexions of the tendons with the radius are purposely left undisturbed.
Attention is now directed to the palmar side of the incision. The anterior
surface of the ulna is cleared by cutting towards the bone so as to avoid the
artery and nerve; the articulation of the pisiform bone is opened, if that has
not been already done in making the incision, and the flexor tendons are separated
from the carpus, the hand being depressed to relax them. While this is being
done, the knife is arrested by the process of the unciform bone, which is clipped
through at its base with pliers. Care is taken to avoid carrying the knife
further down the hand than the bases of the metacarpal bones ; for this, besides
inflicting unnecessary injury, would involve risk of cutting the deep palmar
arch, the position of which is shown in Fig. 3. The anterior ligament of the
wrist-joint is also divided, after which the junction between the carpus and
metacarpus is severed with cutting-pliers, and the carpus is extracted by seizing
it from the ulnar incision with a serviceable pair of sequestrum forceps, and
touching with the knife any ligamentous connexions that may remain undivided.
The hand being now forcibly everted, the articular ends of the radius and ulna
will protrude at the ulnar incision, and are carefully examined and treated
according to their condition. If they appear sound or very superficially affected,
the articular surfaces only are removed. The ulna is divided obliquely with
a small saw, so as to take away the cartilage-covered rounded part over which
the radius sweeps, while the base of the styloid process is retained. The ulna
is thus left of the same length as the radius, and this greatly promotes the sym-
metry and steadiness of the hand, the angular interval between the bones being
soon filled up by fresh ossific deposit. The end of the radius is then cleared
sufficiently to permit a thin slice to be sawn off parallel to the general direction
of the inferior articular surface. For this purpose it is scarcely needful to
disturb the tendons in their grooves on the back of the bone, the bevelled un-
grooved part being enough to remove, and thus the extensor secundi internodii
pollicis may never appear atall. This may seem a refinement ; but the freedom
with which the thumb and fingers can be extended, even within a day or two of
the operation, when this point is attended to, shows that it is important. The
articular facet on the ulnar side of the bone is then clipped away with bone
forceps applied longitudinally. If, on the other hand, the bones prove to be
deeply carious, the pliers or gouge must be used with the greatest freedom ;
for it is of course far better to take away too much bone than too little, and
my earlier cases, as well as some more recent ones to which I have not yet alluded,
prove that a useful hand will result in spite of very extensive excision. The
metacarpal bones of the fingers are next dealt with on the same principle, each
being in its turn closely investigated, the second and third being most readily
430 ON ‘EXCISION, OF THE WRIST) FOR CARTES
J
reached from the radial incision, the fourth and fifth from the ulnar side. If
they seem sound, the articular surfaces only are clipped off, the little facets
by aie they articulate with one another being removed by the longitudinal
application of the pliers, as is indicated in Fig. 3. On the other hand, we have
had in Case 4 an illustration of what may be required when the disease proves
extensive ; for it may be remembered that in that case it was necessary not
merely to take away the whole base of the metacarpal bone of the middle finger,
but to drill its entire shaft into a hollow tube, and yet a sound and most useful
hand was retained.
The trapezium is next seized with a strong efficient pair of forceps, and
dissected out so as to avoid cutting the tendon of the flexor carpi radialis, which
is firmly bound into the groove on its palmar aspect, the knife being also kept
close to the bone elsewhere to preserve the radial artery. The thumb being
then pushed up longitudinally by an assistant, the articular end of its metacarpal
bone is cleared and removed. This may seem a superfluity, as this bone articu-
lates with the trapezium by a separate joint. But besides the possibility of
its being affected through its immediate vicinity to the other articulations,
the symmetry of the hand is promoted by reducing it to the same level as the
other metacarpal bones. Lastly, the articular surface of the pisiform bone
is clipped off, the rest of the bone being left, 1f sound, as it gives insertion to
the flexor carpi ulnaris, and affords attachment to the anterior annular ligament,
and may serve other useful purposes in the palm. But if there is any suspicion
of its unsoundness, it must be dissected out completely. The same applies
to the process of the unciform. It may be observed that the extensors of the
carpus are the only tendons divided ; for the flexor carpi radialis is connected
with the second metacarpal bone below its base, and so escapes. But if it should
be cut, there is no doubt that, like the extensors, it would acquire new and
secure attachments. The tourniquet being now removed, it will probably
be found that either no vessel at all requires ligature, or merely one or two
superficial branches. The radial incision is stitched closely throughout, and
also the ends of the ulnar incision, as it is desirable that union should take place
there, and more especially over the end of the ulna; but the middle of this
incision must be kept open by pieces of lint introduced lightly into the wound
to give support to the extensor tendons, and to ensure a wide opening into the
cavity, which may serve for the free exit of the pus which must necessarily
be formed there. The limb is placed upon a suitable splint, and dressed with
some porous material, arranged so as to avoid pressure upon the lines of incision,
in order that it may absorb without obstructing the discharge.
To the general reader the above description will, I fear, have proved weari-
ON EXCISION OF THE WRIST FOR CARIES 431
some; but to any one about to perform the operation, all the details will, I
believe, be found well worthy of attention. The procedure consists, in fact,
of a series of operations, each one of which must be executed with scrupulous
care. But none of them will present any difficulty to a surgeon who has refreshed
his knowledge of the anatomy of the parts, and carefully studied the various
successive steps of the process. The operation is, however, necessarily tedious ;
and no one ought to undertake it who is not prepared to bestow upon it a great
deal of patient attention. But, considering the importance of its object, its
tediousness must not be regarded as an objection, more especially as the surgeon
alone feels the disadvantage. or the tourniquet prevents the loss of a drop
of blood beyond what is in the veins of the hand at the outset, and the patient
sleeps tranquilly under chloroform; and if this is given by any intelligent
assistant in accordance with the safe and simple principles which I first learned
in the Edinburgh school—and have since done my best to diffuse,! but which,
I regret to say, are still too little appreciated by the profession—it is a matter
of entire indifference whether its administration is continued half an hour or
an hour and a half. Under such circumstances, anything like hurry is as
uncalled for as it would be fatal to success.
The after-treatment also requires much care, and has undergone great
improvement through experience ; and, indeed, the superior results obtained
in the more recent cases are due even more to this cause than to the better
method of operating.
The principal objects to be kept in view are, to maintain flexibility of the
fingers by frequently moving them, and at the same time to procure firmness
of the wrist by keeping it securely fixed during the process of consolidation.
To the latter indication I paid scrupulous attention from the first ; and
hence I have in no instance met with any approach to the flail-like condition
of the new joint which otherwise would certainly have occurred. Indeed,
my anxiety to avoid interference with the process of repair at the wrist led me
at first to abstain from moving the knuckles, and to restrict the exercise of
the fingers to their middle and distal joints. Consequently, in the earlier cases
the movements of the knuckles are still very limited ; experience having shown
that any one joint which is not freely and frequently moved is apt to become
permanently rigid. Another circumstance which interfered at first with my
obtaining the best results was a needless dread of suppuration of the opened
sheaths of the tendons, which made’ me afraid to disturb them during the first
week. 3ut I was gratified to find, in case after case, that nothing of the sort
' For an investigation of these principles see an article on Anaesthetics, by the author, in Holmes’s
System of Surgery, vol. ui, third edition (reprinted at page 135 of vol. 1).
432 ON EXCISION OF THE WRIST FOR CARTES
=—
ever occurred—a fact which must, I suppose, be attributed to the entire absence
of tension in the soft parts, ensured by the free removal of the bones. Thus
I have gradually grown more bold, and now do not scruple to ask the patient
to demonstrate his command over the joints of the thumb and fingers on the
first day, and make a point of commencing passive motion on the second day,
whether the inflammation has subsided or not ; and from this time forth it is
continued daily till it ceases to be necessary. In executing these movements
each finger is both flexed and extended to the full degree which is possible in
health, care being taken that the metacarpal bone concerned is held quite
steady, to avoid disturbing the wrist.
By proceeding in this way, even though the fingers have been previously
stiff, it is easy to maintain the suppleness produced by the free movement under
chloroform immediately before the operation as recommended above. [or an
adhesion only one day old yields without much force on the part of the surgeon
or much pain to the patient, whereas a very few days will give it such firmness
as will require great violence to rupture it. .
The splint which I used originally was a flat one, on which the hand lay
with the fingers extended. But I have found it a great improvement to have
the hollow of the palm supported upon an obtuse-angled piece of thick cork
(Fig. 5, C) attached to the splint, a convenient cement for the purpose being
gutta-percha fused with a hot iron. The hand thus lies semiflexed, which is
its natural position of repose ; and has also the advantage that the fingers are
midway between the extremes of flexion and extension into which it is necessary
to bring them in the daily passive movements, while a certain range of voluntary
motion is also permitted, which the patient should be encouraged to exercise
frequently during the day. At the same time, this position is best adapted
for allowing the extensors of the carpus to acquire fresh attachments. Lastly,
the palm being applied to the sloping surface of the cork, the splint is kept from
slipping upwards ; while any movement in the opposite direction is prevented
by giving the turns of bandage which encircle the wrist a purchase upon a trans-
verse bar of cork (Fig. 5, D) attached to the under surface of the splint about
the level of the knuckles. The great essential as regards the wrist—that of
perfect steadiness—is thus effectually secured, the hand remaining fixed through-
out the day, however freely the fingers be moved. While the patient is confined
to bed the limb should rest upon a sloping piece of wood or desk, which is much
more steady than a cushion, the inner condyle being well padded with cotton
to avoid bed-sore.
The bar of cork beneath the splint has the further advantage of allowing
the thumb to fall below the level of the rest of the hand into the position in
ON EXCISION OF THE WRIST FOR CARIES 433
which it is most serviceable for opposition to the fingers. For if it be pushed
upwards by resting on a board or cushion, it will be apt to retain permanently
its unnatural attitude ; its basis of support, removed in the operation, being
reproduced in accordance with its altered circumstances. For the same reason,
the piece of cork on which the hand rests should be well hollowed to receive the
ballofthethumb. The thumb itself is apt to become drawn, in time, towards
the index-finger, which would greatly impair its usefulness ; but this is readily
avoided by taking the precaution of keeping the thumb, from the first, completely
extended by a substantial pad of cotton in the angle between it and the fore-
finger, the pad being of course removed once every day for exercise of the joints.
Pronation and supination, also, must not be long neglected; and as the
Fic. 5.—a represents the splint, of which 4 B is the wooden
part; C, the piece of cork to support the hand; D, the transverse
bar of cork beneath; £, the ledge of gutta-percha for the ulnar
border of the hand to rest on; F, another ledge of gutta-percha.
b shows the limb bandaged to the splint.
new wrist acquires firmness, flexion and extension, abduction and adduction,
should be occasionally encouraged.
As to the length of the period during which passive motion may be required,
the rule must be to continue it till the disposition to contract adhesions finally
ceases, and this may be after a few weeks or not till months have elapsed.
When the patient leaves his bed and carries his arm in a sling, the weight
of the hand will make it gradually droop to the ulnar side, unless it is properly
supported. This is conveniently done by affixing two ledges of gutta-percha
(Fig. 5, E and F) to the ulnar side of the splint—one for the border of the hand
to rest on, and another, towards the upper part of the forearm, to keep the splint
from shifting laterally
' When the hand acquires strength enough to be useful, more free play for
the fingers should be allowed by cutting off the part of the splint on which they
434 ON EXCISION OF THE WRIST FOR CARIES
rested—viz. all of it beyond the knuckles, leaving only enough to support the
hollow of the palm. The thumb must also be left free for use during the day,
but at night it should still be kept extended with the pad before mentioned ;
and if there be any defect in extension of the fingers, they may be kept bound
at night to a piece of thick gutta-percha applied to the back of the limb, and
bent upwards at an angle at the knuckles. The gentle and continuous traction
of the elasticity of the gutta-percha will soon correct the fault.
With regard to the dressing, after the first twenty-four hours I have found
a poultice the best application for a few days, and afterwards lint soaked in
a solution of some stimulating agent, such as sulphite of potash, which I tried
some time ago, on theoretical grounds, for,the treatment of sores, and have
found preferable to the ordinary astringents, diminishing the amount and fetor
of the discharge, and producing a very healthy state of the granulations. It
may be used in the proportion of ten grains to an ounce of water.
Even after the hand is healed some support will still be required for a con-
siderable period, and this may be conveniently made of bend leather, accurately
moulded to the anterior aspect of the limb, and reaching from about the middle
of the forearm to the level of the knuckles, which it rises to support, its ulnar
border being turned up for the side of the hand to rest on, while at the radial
side it gets a purchase on the base of the metacarpal bone of the thumb. A few
turns of bandage, or a laced piece of soft leather, above the wrist, will be
sufficient to keep it securely in position, the apparatus scarcely showing at all at
the back of the hand.
This support must be worn till the patient feels the wrist exactly as strong
without it as with it. It isa most serious mistake to lay it aside too early. Case
I, in which after the lapse of a year and three-quarters the necessary condition
for abandoning it was at last fulfilled, is a striking instance of the advantage
derived from its persevering employment. Considering the very large amount
of bone removed in that case, I confess I hardly hoped for such perfect firmness
as was ultimately attained ; and I feel sure that if the rule I have given had not
been followed, the result would have been very different. The use of the support,
far from hampering the motions of the fingers, favours their usefulness. For
it seems to be a principle in physiology that the nerves refuse to call the muscles
into action unless they can do so with effect ; and so, when the wrist has not the
firmness mechanically necessary for the efficient action of the fingers, their move-
ments are feebly executed ; but when the wrist is firmly supported, the motor
apparatus of the hand is, so to speak, encouraged to its best efforts, and recovery
of the power of the limb is greatly promoted.
One or more sinuses may remain open for a long time, just as after excision
ON EXCISION OF THE WRIST FOR CARIES 435
of the elbow-joint, without anything being wrong with the bones; as, for
example, in the case of Margaret W—— (Case 2), in which they did not finally
close for more than a year after the operation. Or, again, the persistence of
sinuses may depend upon small exfoliations, and these may prove extremely
slow in separating. This may be illustrated by
CASE 7, that of James M‘'G——, sixteen years of age, whose right wrist
I excised on the 21st of November, 1863, on account of disease of spontaneous
origin, which had attained to much the same exaggerated degree as in Helen
M—— (Case 4), and presented similar apparently hopeless appearances: the hand,
greatly swollen and discoloured, and with numerous sinuses and a grey palmar
sore, hanging helpless at an angle of about sixty degrees, with the fingers stiff and
clawed. The radius and ulna were very freely resected, and it was necessary to
apply the gouge to the third and fourth metacarpal bones on account of extension
of the disease below their bases. All went on well after the operation, except
that a sinus remained in each line of incision, and a probe introduced into that
on the ulnar side passed down to bare bone of irregular surface. This made
me fear a return of the disease ; but, as the wrist was growing firm and the hand
useful, I did not interfere, and after the lapse of ten months a small exfoliation
escaped from the ulnar aperture. The probe, being then introduced, no longer
came in contact with any bone; and now, three months later, the sinus has
become reduced to an almost invisible aperture, which yields only a minute
drop of limpid lhquid, while the new joint at the wrist is all that can be desired
both in firmness and flexibility.
Hence so long as swelling and discharge diminish, and the strength of the
hand increases, no interference is called for. But should the opposite conditions
present themselves, recurrence of the disease must be suspected, and the part must
be submitted to a thorough exploration, which should not be too long delayed,
since caries reappearing at a limited spot will spread in time to all the bones.
This course I have found it necessary to adopt in more than one instance,
as, for example, in the following case, which was in some respects the worst
I have had to deal with. .
CASE 8.—Mrs. C——, aged twenty-five, a married woman, came to the
infirmary for the purpose of having her right hand amputated, on account of
spontaneous disease of the carpus of two years’ standing, attended for eighteen
months with constant discharge, and for the last six months with such severe
pain as to deprive her to a great extent of her night’s rest, while the effect
upon her general health was marked by her wasted and sallow aspect, impaired
appetite, and rapid pulse.
436 ON EXCISION OF GHP AViRIST FOR) CARES
Some idea of the appearance of the wrist may be gathered from the accom-
panying illustration (Fig. 6), taken from a photograph, and also from the fact
that the wrist measured nine inches and three-quarters in circumference, whereas
the sound one was slender both from natural conformation and from emaciation.
The surface of the swollen part was studded wth eight sinuses, through which
the probe could be passed down to diseased bone in the forearm, the carpus,
and the metacarpus. The hand drooped when the arm was extended, and the
fingers were entirely useless. On the 8th of June, 1864, I performed the operation,
which proved very laborious on account of the condensation of
the soft parts and the extraordinary enlargement of the radius
from inflammatory hypertrophy, which made it impossible to
protrude it as usual at the ulnar incision for the application
of the saw, while its texture was so hard as to require con-
siderable force with the most powerful cutting-pliers to divide it.
For seven weeks all went on perfectly well, so that at the
end of that time the circumference of the wrist was diminished
by an inch, and she could readily pick up a light object with
the finger and thumb of the unsupported hand, which drooped
but slightly below the horizontallevel. She was also quite free
from uneasiness, and her general health was greatly improved.
Unfortunately, however, the sores, which were previously healing
kindly, were now attacked by hospital gangrene ; and though
this was checked in about five days by the application of nitric
acid and other measures, the previously satisfactory progress
was no longer observed ; and, when a month had elapsed with-
out improvement, I resolved to investigate the cause. Having
put her under the influence of chloroform, I opened up the line of
the ulnar incision, and, finding the end of the ulna again carious,
removed it with pliers ; but was pleased to find, on introducing
my finger into the cavity that still existed, that the large cut surface of the
radius was smoothly covered with granulations, as also were the ends of the
metacarpal bones. I therefore brought the edges of the incision together by
stitches, except a part sufficient for the escape of discharges, and placed the limb
again upon the splint. From that time forth she has advanced satisfactorily ;
and when she last came from her native town to see me (December 1864), the
discharge had almost entirely ceased, the swelling was greatly reduced, and
although the end of the radius was still very large, and the wrist measured eight
inches and a quarter in circumference, the border of the bone was to be felt
immediately beneath integument of normal thickness and consistence, and
HIG..6:
s
ON EXCISION OF THE WRIST FOR CARIES 437
J
the hand had a thoroughly natural appearance. She could extend it unsup-
ported without any droop, and even raise it above the level of the forearm by
muscular effort. She had discarded the sling, and, by help of a light splint,
found the hand of much use to her, the movements of the thumb and fingers
being very satisfactory.
In this case return of the disease appeared to be produced by an attack of
hospital gangrene, and I am inclined to attribute to the same cause a similar
occurrence in the following instance.
CASE 9.—Alexander C——, aged eighteen, a calenderer, was affected with
spontaneous caries of the ulnar side of the right carpus, for which I performed
excision of the wrist on the 22nd of July, 1864. Four days afterwards the
ulnar incision was affected with hospital gangrene, which was subdued in the
course of a few days by local treatment. The hand then progressed very
favourably up toa certain point, and in a few weeks he could freely flex and extend
all the joints of his fingers, which before the operation he could scarcely move,
and had perfect use of his thumb and a strong wrist. The ulnar incision,
however, refused to heal completely, and the soft parts in the vicinity continued
thickened, and towards the close of the year the swelling there appeared to be
on the increase. Suspecting some return of the disease, I opened up the ulnar
incision on the 2nd of December, but could not find anything amiss. The
wound, however, continued remarkably languid, making in three months scarcely
any progress in healing ; and at length, on passing the probe down to the pisi-
form bone, I felt it bare and rough. Accordingly, on the 28th of February,
1865, I put the patient under chloroform, and, after extending the incision
sufficiently to gain access to the pisiform, I dissected out the whole of that bone,
which was the only diseased part that I could discover. During the month
that has since elapsed, the healing, so long delayed, has made good progress,
and as there is now no discharge from the deeper parts, I hope to see the hand
before long soundly cicatrized. ;
There is yet a third case with which hospital gangrene appears to have had
the same relations.
CASE 10.—Jane S——, aged twenty-three, a millworker, with idiopathic
caries of the right carpus, had the wrist excised on the 23rd of March, 1864.
For two months and a half the appearance and power of the hand promised
an excellent result, when it was seized with hospital gangrene, and from that
time it gradually deteriorated, till at length, on the 26th of August, I explored
it under chloroform, and found very extensive disease in both bones of the
forearm and in the metacarpus. I removed with cutting-pliers the affected
438 ON EXCISION OF THE WRIST POR CARLES
parts, so far as I was able to judge of their extent ; but I omitted to examine
the metacarpal bone of the thumb, and, whether in consequence of this or not
I will not pretend to say, the operation did not prove successful ; and on the
29th of January, 1865, being loth to sacrifice the hand, I re-excised a second
time, and found carious disease again present in the ends of all the bones,
including the metacarpal bone of the thumb, which this time I made a point
of examining, reopening the radial as well as the ulnar incision. The operation,
however, was an extremely troublesome one, and far from being as definite
and satisfactory as a primary excision ; and even now, although she can move
the thumb and fingers, and it is evident that the hand would be a thoroughly
useful one if it would heal, I feel by no means satisfied that it will do so.
The lesson to be learned from such a case is the necessity of using all means
by which recurrence of the disease may be avoided, and not too long delaying
exploration of the wrist when it is suspected.
It remains to say a few words regarding the mode in which the new joint
at the wrist is produced. It appears that the bones of the forearm and of the
metacarpus become approximated, partly by shortening of the limb and partly
by the growth of new osseous material from their divided ends ; and I find that,
as a general rule, about half an inch in length of new bone is formed, and that
the rest is effected by shortening. The new bone appears to be generally
developed in about equal proportions from the radius and ulna and from the
metacarpus, but sometimes in an irregular manner. Thus in two instances
I have observed a process grown from the ulnar side of the radius, and received
between two lateral portions from the metacarpus, so that a secure joint on
an entirely new principle was the result.
With proper care on the part of the surgeon, perfect symmetry of the hand
can be always ensured; for the radius and ulna above, and the metacarpus
below, being divided in parallel lines, the shrinking of the new material between
them draws the hand equably upwards towards the forearm. In this respect
the operation above recommended has a great advantage over any partial
procedure in case of disease apparently confined to one side of the carpus,
independently of the paramount consideration of its greater security of eradi-
cating the caries. And any scruple which I might once have felt in recom-
mending total excision for limited disease has been entirely removed by the
usefulness of the hands which have been subjected to it.
It will no doubt appear desirable that I should allude, however briefly,
to the rest of the cases that have come under my care. They are five in number,
and include some of the best and some of the worst. Among the former is
to be mentioned, first, my last case, that of E. P——, aged thirteen, a strumous
ON EXCISION OF THE WRIST FOR CARIES 439
girl, whose right wrist was excised on the 27th of November, 1864, for caries
limited to the lower and outer part of the carpus and the base of the second
metacarpal bone, which appeared to be affected with tubercular deposit. The
hand had been useless for a year, but is now already useful as well as sound and of
perfect shape, with better movements than in any former case at the same stage.
Next is James B——, aged twelve, with disease of the left wrist, limited
to the lower and ulnar side of the carpus and the fifth metacarpal bone, which
was enormously thickened and diseased in its interior throughout almost its
entire length. Rest and constitutional treatment having been tried in vain
for five months, I proceeded to operate on the 14th of August, 1864, and, instead
of adopting what would, I believe, be the usual course (amputation of the little
finger and its metacarpal bone, with the probability of the disease continuing
in the carpus), I excised the wrist, leaving the little finger, though it was necessary
to drill its metacarpal bone into a tube with the gouge. He has now a beautiful
and most useful hand, which is constantly increasing in strength, though there
still remains a sinus over the base of the fifth metacarpal bone, from which
a small exfoliation recently escaped.
Third in order must be placed Andrew C——, aged nine, with disease of
the left wrist of eight months’ standing, and in so severe a form as to call for
immediate treatment. The caries extended from the forearm to the meta-
carpus, and had produced great destruction in the carpus. The operation was
performed on the 26th of November, 1864, and the result has been very satis-
factory as regards the improvement in the general health, the strength of the
wrist, and the mobility of the thumb and fingers. But there have remained
hitherto (four months) two small sores unhealed, and these within the last few
days have been affected with hospital gangrene. This has, however, been
checked by the application of carbolic acid, and I hope has not penetrated
to the bones.
Lastly, I have to record two deaths. Neither of these, however, was
directly connected. with the operation. One of the patients, Alex. 5——,
a stone-mason, aged forty-six, the first I operated on, was in truth not a fit subject
for excision, except as a means of relieving him of the agonizing pain which
he endured from disease of the right wrist ; for he was affected with advanced
phthisis as well as other complaints, and died of these seven weeks after the
operation, which, however, had made him free during the interval from his
previous suffering.
The other fatal event occurred also in one of my early cases. The patient
Neil C——, aged twenty-one, had the right wrist excised on the 4th of July,
1863, for extensive strumous caries. But in consequence, as I suppose, of
440 ON EXCISION OF THE WRIST FOR CARIES
the imperfection of my first mode of operating, the disease recurred, and, after
waiting in the vain hope of improvement for about six months, I explored
the bones and performed re-excision. A few weeks later—namely, on the
28th of February, 1864, a spot of redness appeared on the forearm, about mid-
way between the wrist and elbow, and next day he had a severe rigor. I was
at once called to see him, and, finding evidence of inflammation of a superficial
vein leading upwards from the red spot to the elbow, I thought there might
be a chance of arresting the pyaemia in its outset by amputating the arm, which
I did about three inches below the shoulder, within an hour and a quarter of
the occurrence of the first rigor. On examining the veins, I found a mixture
of pus and blood in the vessels of the forearm, while those of the arm appeared
quite sound. Sulphite of potash, in ten-grain doses, was now administered
every three hours, with the view of counteracting the poisonous effect of any
septic matter already introduced into the circulation, and this was continued
till the 5th of March. After this time he improved for several days in general
health, while the stump was progressing favourably ; but just as I was con-
gratulating myself on a cure of pyaemia, pulmonary symptoms appeared, and
carried him off on the 23rd of March, twenty-three days after the amputation.
Whether the affection of the lung was an aggravated condition of the phthisis
under which he laboured, or an unusually remote effect of the pyaemia,
I unfortunately had not the opportunity of ascertaining by post mortem
examination.
In no instance have I been troubled with secondary haemorrhage or any
other bad symptom immediately referable to the operation, which appears to
be a peculiarly safe one.
A general review of the cases above related may be stated shortly as follows.
I have excised the entire articular apparatus of the wrist in fifteen patients.
Of these, two have died of causes independent of the operation, and of the
remaining thirteen, one is in an unsatisfactory condition, but not hopeless,
two afford good hope of a satisfactory termination, which in the remaining ten
may be said to have been already arrived at.
On comparing these results with those of previous practice, bearing in mind
that the cases include all varieties of carious disease, sometimes in the most
aggravated form ever likely to be presented, and also that they have been treated
under the disadvantages of hospital atmosphere, so that I have had to contend
in no less than six instances with hospital gangrene and in one with pyaemia
it will, I trust, appear that the principles which have guided me are sound,
and afford the means of removing one of the greatest opprobria of modern
surgery.
CLINICAL LECTURE ON A CASE OF EXCISION OF
THE KNEE-JOINT, AND HORSEHAIR AS A
DRAIN FOR WOUNDS, WITH REMARKS ON
THE TEACHING OF CLINICAL SURGERY
Delivered at King’s College Hospital, December 10, 1877
’ Sa i
[Lancet, 1878, vol. i, p. 5.]
GENTLEMEN.—I bring this little girl before you to-day because it is important
that you should not only see the patients when they first come under our care
in the hospital, not merely have the diagnostic features of their diseases pointed
out to you, hear the appropriate treatment discussed, and witness any operations
that may be performed, but also follow the after-progress of the cases, and
further, because by bringing her into the theatre I can show you what I wish
you to notice regarding her very much better than by taking you to her bed
in the ward.
Let me remind you of the essential features of the case. | As she was brought
before you ten days ago, the left knee was bent considerably beyond a right angle,
the leg being in fact at an angle of about 45° with the thigh, and we were given
to understand that this condition of things had existed from the age of three
years, when she was affected with a disease of the knee-joint up till the time
of her admission to the hospital at the age of ten. The scar of a sinus was
present at one side, but it had long since healed. The lmb in that position
was of course worse than useless. I also pointed out that it was atrophied ;
or, to speak more correctly, had lagged behind the other in growth; so that
the fibula was 14 inches shorter than the other, and there was a difference of
eleven-sixteenths of an inch between the two feet as measured from the point
of the caleaneum to the end of the great toe.
I may remark that this atrophy, or lagging behind in development, seems
to be interesting as explaining, in part at least, the corresponding fact after
excision of the knee. If that operation is performed in early childhood, it is
often observed that as the patient grows to adult life the affected limb is more
or less considerably smaller than the sound one. This has been supposed to be
due to taking away too much of the ends of the bones so as to deprive them
of their epiphyses, but a case like the present points to another explanation.
LISTER II Gg
442 ON A CASE OF EXCISION OF THE KNEE-JOINT
a
Here no portions of bone at all had been taken away, no active disease had been
present for several years, and the only abnormal circumstance was that the
limb had been in a condition incapable of being used like the other. In con-
sequence of this want of use, not only had the muscles atrophied, a thing which
you would all have anticipated, as the converse of the hypertrophy that occurs
in the blacksmith’s arm, but all the textures, including the bones, had grown
in a less degree than in the healthy limb. Similarly, after excision, although
the operation be successful, and perfect anchylosis between the femur and tibia
be attained, the limb is not so vigorous as the other, and in proportion to its
diminished activity may its growth be interfered with. I lately saw a case
in private practice which illustrates this point still more strikingly. The patient
was a boy who had experienced fracture of both bones of the leg in the lower
third when a child. The fracture had been overlooked, and the bones had
united in a faulty position, so that the foot was considerably inverted. The
boy therefore could only walk upon the outer edge of his foot, and that with
a very limping gait, except by the aid of an apparatus which, though it enabled
him to tread fairly on the sole of his foot, was in itself necessarily cumbrous ;
and the result had been a shortening of the limb, as compared with the other,
altogether out of proportion to the effect of the curved position in which the
bones had united ; and, just as in the case before you, the foot also was smaller
than its fellow. There the interference with full development induced by
imperfect action of the limb was still more plainly illustrated than in this little
girl, because in the former there had been no disease at all from first to last,
but merely the crippling influence of an injury.
To return to the case of the little girl. We had to deal with a limb which
was not only useless from its bent position, but which had been so retarded in
its growth that, even if perfectly extended, it must be shorter than the other.
Hence it was a matter of the utmost importance that the means which should
be used to produce extension should add as little as possible to the existing
deficiency in length. The joint was not anchylosed, but the hamstrings became
extremely tight on any attempt at extension. We therefore proposed to divide
the hamstrings by subcutaneous tenotomy, but I led you to fear that this step
might not be sufficient to enable us to restore the straight position ; for I men-
tioned to you the fact first brought prominently forward by Prof. Volkmann,
of Halle, that in cases like this, in which the knee remains for a long time in
a bent position, the lower end of the femur, no longer supported as usual by the
articular surface of the tibia, may experience disproportionate growth in the
downward direction, often to a very considerable extent. Meanwhile the
* See a translation of Prof. Volkmann’s paper in the Edinburgh Medical Journal, vol. xx, p. 794.
AND HORSEHAIR AS A DRAIN FOR WOUNDS 443
lateral ligaments remaining of normal shortness, while the articular portion
of the femur is abnormally lengthened, the tibia becomes locked against the
femur when extension is attempted, and the application of violence for the
purpose could only lead to backward dislocation. Accordingly we found that
after free division of all the hamstrings, together with all tight bands of popliteal
fascia, the tibia did become locked in the way I had anticipated, when we tried
to straighten the limb.
The abnormal length of the end of the femur being presumably the essential
obstacle to extension, I proceeded to reduce it, opening into the joint with a
semilunar incision anteriorly without dividing the lateral ligaments, and paring
away successive portions of the articular part of the femur until, some super-
fluous fibrous tissue of new formation having been also removed from the surface
of the tibia, I was at length able to effect complete extension, but not without
a degree of pressure of one osseous surface against the other which I should
not have felt justifiable without antiseptic means.
The manner in which drainage was provided is a point worthy of your
attention. Next to the importance of the avoidance of putrefaction in wounds
is the prevention of tension by providing a free escape for effused blood and
serum. This we have hitherto generally done by means of the caoutchouc
drainage-tube of Chassaignac. But in the present case such a tube would have
been unsuitable, because the natural position for the drain was that it should
run between the ends of the bones which, as we have seen, were pressed together
so that the calibre of a caoutchouc tube would have been altogether obliterated,
and the drain in a most important part of its course rendered useless. Under
these circumstances I used a drain of horsehair, because such a drain operates
by capillary attraction through the interstices between the hairs, and those
interstices cannot be obliterated by pressure, seeing that the hairs are not
individually compressible.
The drain was introduced in a manner which you will often find useful.
It may frequently happen that the most dependent part of a wound may have
no opening in the skin to correspond with it : thus after excision of the mamma
it may turn out, when the operation is concluded, that the wound presents
a pocket extending considerably further back than the outer angle of your
incision. Under such circumstances it is desirable to make an opening for the
exit of the drain at the most dependent part. Now, if this were done by a punc-
ture with the knife, some arterial branch of considerable size might be wounded,
involving the necessity of freely enlarging the wound to secure the bleeding-
point. But if you take a pair of dressing-forceps, and bore steadily from within
outwards, the conical extremity of the instrument will slip past any arterial
Gg2
T
444 ON A CASE OF EXCISION OF THE KNEE-J@INe
branch or nervous trunk without injuring it, and when at length it is apparent
that there is nothing but skin between the instrument and the surface, the
tough integument is divided with a knife over the point of the forceps, and the
blades being forcibly expanded so as to enlarge somewhat by laceration the
opening which has been made in the muscles, or other deeper textures, the
drain is seized between the blades of the forceps, and drawn into place. So
in the present case the most eligible position for a dependent opening was at
the outer aspect of the limb, where the use of a knife would have involved the
risk of injuring the external popliteal nerve, or of dividing some articular arterial
branch. Any such difficulty was avoided by employing the dressing-forceps
in the manner described.
It is only right that I should mention, when alluding to the horsehair drain,
that its use did not originate with myself. We were led to its adoption in the
following manner. Mr. Chiene, of Edinburgh, suggested some time ago the
employment of catgut as a substitute for the caoutchouc tube. He hoped by
this means to provide adequate drainage through capillary attraction, and at
the same time, by virtue of the proneness of the catgut to absorption, to do
away with the necessity for the withdrawal of the drain from time to time,
which there is when the caoutchouc tube is used, whether for the purpose
of shortening the tube or substituting a small one for a large. Mr. Chiene’s
anticipations were to a considerable extent realized. In all cases in which
the wound remained aseptic the absorption of the deeper part of the catgut drain,
and consequent falling off of the part outside the wound, might be reckoned
on as a matter of course ; and in several cases in which the catgut was so used,
both by Mr. Chiene and afterwards by myself, the drainage proved adequate
and satisfactory. Mr. White, of the Nottingham General Infirmary, afterwards
substituted horsehair for catgut ; not because it was supposed to be superior,
but because, whereas the prepared catgut is a somewhat expensive article,
a horse’s tail is a very cheap one. A notice of this use of horsehair was pub-
lished by Mr. White’s house surgeon, Dr. L. W. Marshall, in the Lancet of the
2nd of December, 1876 ; and in the following month it was employed by myself
in the Edinburgh Royal Infirmary, in a case of chronic bursitis of the sheaths
of the flexor tendons at the wrist, in which it seemed likely to be peculiarly
serviceable. In this affection the bursa is distended both above the wrist and
in the palm, the cavities thus constituted being connected by a constricted passage
under the annular ligament ; and it is desirable that both the expanded parts
should be opened to give exit to the fibrinous concretions which are generally
present (varying in size from that of a millet-seed to that of a small bean), and,
further, that drainage should be provided for effused serum, the operation being
AND HORSEHAIR AS A DRAIN FOR WOUNDS 445
performed antiseptically, in order to avoid the very serious inflammatory dis-
turbance and suppuration which are otherwise apt to occur. I had previously
used the caoutchouc tube as a drain in such a case, but I found a difficulty from
the lability of the tube to be compressed by the tendons. This might, I thought,
be overcome by the use of the horsehair drain, which at the same time would,
for this particular purpose, be superior to one of catgut, because the catgut
would probably be absorbed before the necessity for drainage would be over.
Accordingly I cut down above the wrist, making my way between the tendons
of the flexor sublimis to the distended sheath of the flexor profundis, and, as
soon as this was opened, passed in a large bullet-probe, somewhat curved, slipped
it along under the annular ligament, and pressed it forcibly towards the palm,
so as to perforate the palmar fascia while avoiding injury to the palmar arch,
and, having divided the skin over the point of the probe, dilated the opening
in the fascia with dressing-forceps, and then passed into the eye of the probe
a substantial drain of horsehair, which had been well purified by steeping in
a I to 20 solution of carbolic acid, and withdrew the probe, leaving the horsehair
drain in its track. The drain answered admirably, and presented the further
great advantage that it could be reduced in bulk in accordance with the diminu-
tion of the serous discharge, by drawing out as many hairs as might be desired ;
and in the course of three weeks, the last portions of the drain having been with-
drawn, the wound healed without the occurrence of suppuration from first to last.
While the horsehair has the advantage over the catgut that it can be
used when necessary over a longer period, it has, in some cases, the converse
superiority that it can be not only reduced in bulk, but withdrawn altogether
at an earlier period than is required for the absorption of the catgut ; for the
catgut, in process of organization and absorption, becomes more or less
incorporated with surrounding tissues through the medium of the cells of new
formation which invade it, and, if an attempt is made to withdraw the drain
in whole or in part, there will often occur inconvenient oozing of blood through
the rupture of newly formed vessels. And if, on the other hand, the drain
is left intact till the parts of the catgut within the wound are entirely absorbed,
there remains a small granulating sore at the place of exit of the drain, which
may retard for some days the complete healing of the wound. Further, the
threads of the catgut, as they undergo organization, are increased in bulk by
the formation of the new cells, and their interstices are liable to be more or less
choked, so as to interfere with effective drainage. The horsehairs, on the other
hand, lie unchanged among the tissues, and their interstices remain to the last
as effective as they were at the outset.
The next case in which I used the horsehair drain was one which you your-
446 ON A’ CASE OF EXCISION OF THE KNEE-OERNE
selves witnessed—viz. that of transverse fracture of the patella, treated by
laying open the joint, drilling the fragments obliquely, and tying them together
by means of strong silver wire. Being apprehensive that blood and serum
might be effused into the joint to such a degree as to produce inconvenient
tension unless a free exit was provided, I resolved to introduce a drain at a
dependent part of the articular cavity ; but I feared that, if a caoutchouc tube
was used, it might be rendered inefficient by being compressed between the
condyle of the femur and the neighbouring tissues. I therefore had recourse
to the horsehair, introducing into the posterior and outer part of the joint a
drain, about a quarter of an inch in thickness, by means of the dressing-forceps
employed as before described. It worked to admiration; for though there
was, indeed, in the first twenty-four hours, a very copious sanguineo-serous
effusion, as shown by the soaking of the antiseptic gauze, yet not the slightest
swelling of the joint occurred, and, after nine days, the small remains of the
drain, which had been previously reduced at successive periods, were withdrawn,
to allow the puncture to close. The drain of horsehair was as pure and white?
as if it had been merely dipped in water ; having been washed quite clean of
the blood which first occupied its interstices by the colourless serum which,
after the cessation of the original sanguineous effusion, had been the only dis-
charge. I wasso much impressed with the satisfactory working of the horsehair
drain in that case that we have since employed it in preference to the caout-
chouc tube in all our wounds, and have had good reason to be pleased with the
change. (If it be necessary to reintroduce a horsehair drain, it is readily done
by taking a wisp of hair of half the thickness required, bending it in the middle
at a sharp angle over a probe, and tying a piece of carbolized silk round it close
to the probe, on withdrawal of which the drain is left with a rounded end
which passes readily into the interior of the wound.)
In the case of this little girl the horsehair drain has worked perfectly well
in spite of the pressure to which it was subjected. The flow of blood and serum
was, in the first twenty-four hours, extremely free, but there was no appearance
of the retention of any of it within the wound. On the occasion of the last
dressing, two days ago, more than half of the drain was removed. That dressing
took place after an interval of three days, and it would be superfluous to change
the dressing to-day, were it not that we may, perhaps, be justified, by the further
diminution of the discharge, in withdrawing the remainder of the drain entirely
so as to permit its track to close.
* I used white horsehair in this case simply because I did not happen to have at hand any of the
black, which is generally preferable, because the individual hairs are thicker, while the dark colour has
the advantage of making them more conspicuous, especially when they are used for sutures.
AND HORSEHAIR AS A DRAIN FOR WOUNDS 447
I will now expose the limb before you. We take care that this is done
under a full cloud of spray. We removed at the last dressings both the stitches
of relaxation in the shape of thick wire sutures taking a substantial hold, and
the stitches of coaptation, of horsehair, including only the margins of the wound.
You observe that cicatrization is almost complete, while there is not the appear-
ance of a particle of pus. The skin is still, as it has been all along, free from
inflammatory blush or puffiness. The child has suffered no more uneasiness
than would have been anticipated had forcible extension been practised in a
much less severe case,without the infliction of an external wound, and her con-
stitutional diturbance has been equally trivial. The position of the limb is even
better than at the conclusion of the operation, thanks to the effect of the elas-
ticity of a substantial mass of cotton-wool bound down over the knee outside
the antiseptic dressing, while we have the satisfaction of reflecting that the
bones of the limb have been shortened only by the extent of the abnormal
downward growth of the femur; and I think those of you who have had
experience in surgery will allow that it would have been unjustifiable to have
aimed at such a result without the use of antiseptic measures. If a joint is
excised without such means, all prudent surgeons would agree that enough of
the bones ought to be removed to ensure absence of tension.
On raising the limb, I find that the gauze dressing presents evidence of
discharge, which, though of the nature of colourless serum, is still in sufficient
quantity to make it prudent to retain the drain. We may, however, remove
half of what yet remains, and you observe that I do this by withdrawing
successive hairs without causing the least uneasiness to the child.
Allow me to direct your attention to the splint on which the limb is placed.
It is a piece of Gooch’s splint, a material introduced into surgery by Mr. Gooch,
formerly a surgeon at Norwich, and exceedingly convenient for purposes like
the present. It is made slightly longer than the limb, and as broad as the
semi-circumference of the thigh, cut obliquely at its upper end to correspond
to the line from the perineum to the great trochanter, and at its lower end it
is excavated into a horseshoe to receive the point of the heel. Its flexibility
in the transverse direction permits it to form a trough which is well padded with
a substantial folded sheet made thicker opposite the tendo Achillis, and when
it is bandaged to the limb, the horns of the horseshoe, together with the padding,
form a satisfactory support to the sides of the ankle. The foot is kept slightly
above the level of the groin, and a piece of thin macintosh cloth over the part
of the padding towards the nates sheds the discharge and prevents it from
soiling the padding, while the exact quantity of effused serum can be correctly
estimated. In the course of a short time, when the discharge becomes trifling
448 ON A CASE OF EXCISION OF THE KNEE-JOINT
or nil, a bandage steeped in waterglass (a mixture of the silicates of soda and
potash) will be wound round the limb as it lies in the splint, so as to ensure
absolute immobility.
Now, gentlemen, these various matters have been much more easily demon-
strated to you here than they could have been in the ward. I was much struck
with the difference between the theatre and the ward in this respect when
showing in the ward to some strangers, after our lecture this day fortnight,
the case of large granulating sore which I have brought before you here on
several occasions. Our class is not a large one, numbering only fifty, and
I suppose not half that number accompanied me to the ward. Yet in order to
show the ulcer, it was necessary that those gentlemen should arrange themselves
in two rows, so as to form an alley to admit the light from the window, and even
then they stood in one another’s way, and only those who were very near the
bed could see what would have been shown without any difficulty to the whole
class at once in this place. In connexion with that case I may make some
further remarks regarding the mode of teaching which we employ.
Let me remind you of the various important matters which that ulcer has
afforded the opportunity of demonstrating. First, you recollect how putrid the
sore was at the outset, and how we succeeded in purifying it once for all
by applying to the epidermis soaked with putrid discharge a strong watery
solution (1 to 20) of carbolic acid, which has a special power of penetrating the
epidermis, and to the granulations a solution of chloride of zinc (40 grains to
an ounce), which experience has shown to have an energetic antiseptic effect
upon foul granulations. That we did really purify the sore by this application
was proved to you by the fact that, being afterwards dressed with lint con-
taining boracic acid, which is the mildest of our antiseptics, with a piece of
prepared oiled silk interposed between it and the granulations, to protect them
from the antiseptic, mild as it was, and to ensure constant moisture of the
surface, yet when dressed after an interval of a week, the oiled silk, instead of
being putrid as it would have been in twenty-four hours under a piece of ordinary
lint, had no odour except that of oiled silk itself. The pus had remained free
from putrefaction for that long period, though not directly acted on by an
antiseptic at all.
You have also had demonstrated to you on that sore some very important
truths regarding the properties of granulations. You saw me clip away with
scissors a portion of the surface without occasioning the slightest pain to the
patient, proving that the granulations constituted a protective layer destitute
of sensibility.
Again, we made an accurate pattern of the ulcer in gutta-percha tissue,
AND HORSEHAIR AS A DRAIN FOR WOUNDS 449
and on comparing it with the sore a week later we found that the pattern was
already considerably larger than the granulating surface together with the
cicatrizing margin already forming round it. Thus you had ocular evidence
of the truth that granulations have a tendency to shrink, this being one of the
means by which sores are diminished in extent in the healing process.
You also observed how, when the ulcer was protected, as far as was in our
power, from irritation, by excluding both putrefaction and the direct action
of the antiseptic, the formation of the epidermic pellicle at the edge proceeded
with a rapidity never seen under water dressing.
Lastly, how instructive was the result obtained by skin-grafting. You
saw that whereas before this operation was performed cicatrization took place
only at the edge of the sore, a thin superficial layer of integument, involving
little more than epidermis, having been removed with a sharp knife from the
inner side of the arm, and the shaving having been cut up on the thumb-nail
into small bits, which were placed 1n succession, with the raw surface downwards,
on the granulations, the grafts so planted became each one a centre of epidermic
growth on the sore. Thus was illustrated the general fact in pathology, that
new structures formed in the repair of injuries are composed only of tissues
similar to those in the immediate vicinity, and the equally fundamental fact
in physiology, that severance of a part from connexion with the body is not
followed by immediate loss of its vitality.
You remember also how, having sprinkled the granulating surface with
a sufficient number of grafts, we placed upon the sore the remaining portion
of the shaving, about as large as a fourpenny-piece, and this, as you afterwards
saw, took root and adhered by its entire under-surface, thus teaching us two
great truths. First, it showed that the surface of granulations, if thoroughly
healthy, may unite not merely with granulations, but with a freshly cut surface,
combining, so to speak, union by second intention with union by first intention.
And, in the second place, it afforded of itself conclusive evidence of a most
important pathological fact not yet universally recognised, that granulations
have no inherent tendency to form pus ; for, before sufficient time had elapsed
to cause the death of the portion of integument as the result of its severance
from vascular connexion with the rest of the body, all pus-formation from the
granulations on which it was placed must have ceased ; and not pus-formation
only, but serous oozing also, which would have been equally incompatible with
union of the two surfaces. No sooner did this piece of living dressing, pertectly
unstimulating, chemically or mechanically, protect the granulations, than pus-
formation and exudation of liquor sanguinis were alike suspended.
These, you may say, are very simple matters. Some of them, at least,
450 ON A CASE OF EXCISION OF THE KNEE-JOINT
you might all have done for yourselves. Any one of you might, as a dresser,
clip away a piece of granulations and see that the proceeding was painless,
or any of you might equally easily make a pattern of a granulating sore and
prove to himself its shrinking tendency. You might perhaps have opportunities
for performing skin-grafting ; and might, for aught I know, draw for yourselves
the inferences to be deduced from it.
But, on the other hand, you might very likely fail to do some or all of these
things even in the entire course of your studentship ; and if you do not learn
these matters when students, you may perhaps never learn them at all. Some
of you may become in course of time ‘ pure physicians’, and in that case you
will have no opportunity of studying the healing of sores ; and yet it is a subject
which concerns the physician as well as the surgeon. If the intestines become
ulcerated in typhoid fever, the sores must heal by granulation and cicatrization
in a manner precisely similar to that which occurs in an ulcer of the leg. But
the physician has no opportunity of witnessing this healing process during
life ; and when he sees its effects on post mortem examination, they are probably
marred by the results of decomposition. And so with a multitude of other
things, which it is easy for me to prove to you by demonstration here, but which
the physician can only learn by inference. For medical diseases differ from
surgical diseases not so much in their nature as in their situation; and the
same great principles of pathology, and to a large extent of practice also, must
guide alike the physician and the surgeon.
Now, these great principles may often be illustrated by extremely simple
facts, such as those which you have witnessed in that ulcer. But such simple
and rudimentary, or, so to speak, homely, truths are not only much more easily
demonstrated in the theatre than in the ward, but would very likely never be
taught in the ward at all. In ward visits the surgeon passes from bed to bed,
and points out the most striking features of interest in the various cases ; but
matters of everyday experience, though concerned with the most fundamental
principles of our art, are not likely to receive attention except from some one
who is appointed to discharge the duty of impressing upon his class by way of
demonstration, not only points of unusual interest, but the most commonplace
facts, which, though less attractive, are, in truth, more important to the student.
Thus our clinical course resembles in so far a systematic one that it is our
duty, as the material at our disposal permits, to illustrate all departments of
general surgery ab initio every session. And meeting you so frequently as I do
—twice a week—with an attendance on your part as regular as is given to a
systematic course, I am encouraged to keep my eyes open throughout the session
for the materials requisite for such illustrations.
AND HORSEHAIR AS A DRAIN FOR WOUNDS 451
But though sound general principles are the most important things that
we can discuss together, they are, of course, far from being all that we consider.
Every case of special interest 1s brought before you, its diagnosis is carefully
considered, and the method of treatment to be adopted is discussed in all its
details ; and then, if an operation has to be performed, whether, as is often the
case, in the course of the lecture, or at some other time, you are prepared to
profit by watching its performance, having all the steps of the procedure clearly
in your minds beforehand.
I may take this opportunity of expressing my sincere regret that certain
expressions which I employed before I left Edinburgh should have seemed
capable of interpretation as casting the remotest possible slur on the surgeons
of this metropolis. Nothing certainly was further from my intention. I did,
indeed, while speaking under circumstances peculiarly difficult and embarrassing,
allow an expression to escape my lips which I should not have uttered under
any circumstances had I supposed that my remarks were likely to be published ;
and I am truly sorry for the needless offence which I have thus given. For the
leading surgeons of London no one, I venture to say, entertains higher respects
than myself. I referred not to the London teachers, but to the system on
which clinical surgical lectures were given in London; which, so far as my
knowledge extended, seemed to me essentially inferior to that in use in Edin-
burgh ; partly because they were not demonstrative, and partly because, being
given at rarer intervals and in conjunction with one or more colleagues, they
could not, from the nature of things, approach to the characters of a complete
course.
Not that I wish to underrate such clinical lectures in London as [| refer to.
In proportion to the ability and experience of the lecturer such discourses have
their high value. But referring, as they do, to cases which are not present
before the student, and which many of the audience may perhaps never have
seen at all, they might often, except for the effects of voice and manner, be as
well read as attended. Such lectures are in reality far more ambitious and
involve greater talent and literary effort than ours, which are comparatively
humble performances, standing much in the same relation to a course of
systematic surgery as anatomical demonstrations to lectures on anatomy. But,
simple as they are, they fill a place in the medical curriculum which, I believe,
is second in importance to no other, and which cannot be filled adequately either
by clinical lectures otherwise conducted, or by bedside teaching or tutorial
instruction.
My own conviction of the importance of the subject is, at least, sufficiently
shown by the fact that upon the question whether or not arrangements
452 ON A CASE OF EXCISION OF THE KNEE-JOINT
could be made to enable me to conduct my course here exactly in the same
manner that, following the example of Mr. Syme, I had found so advantageous
in Edinburgh, depended my acceptance or otherwise of the highly honourable
offer of a clinical chair in King’s College.
‘In publishing this lecture I wish to add two remarks in order to avoid
misunderstanding. First, that I do not omit bedside instruction, and always
warn my class that no lectures can possibly take the place of their own individual
work at the bedside, since it is essential, in order that the student may become
a competent practitioner, that he should handle diseases as well as see them,
and not only witness their treatment by others, but be personally concerned
in their management by holding dresserships, &c., in our hospitals. Secondly,
I desire to add that, since I used the expressions in Edinburgh above referred
to, I have been informed that clinical surgical teaching in London has undergone
considerable changes since I was a student, both as regards giving it a more
demonstrative character, and in greater frequency and regularity of meetings
of the classes. The London schools are both numerous and independent, and
the changes to which I allude have, I understand, taken place in different
degrees in different institutions. Hence, I can quite understand that my general
remarks, made, as I would repeat again, without any view to publication, may
have done individual injustice, for which no one could be more sorry than
myself. |
AN ADDRESS ON THE TREATMENT OF
FRACTURE OF THE PATELLA
Delivered at the First Meeting of the Session (1883) of the Medical Society of London.
[British Medical Journal, 1883, vol. ii, p. 855.]
SIR JOSEPH FAYRER, AND GENTLEMEN.—Some time ago, Mr. Holmes
remarked to me that it would be well for me to place before the profession
statistics of the operations which I had performed for fracture of the patella.
And when you, sir, did me the honour to request that I should open this session
of the Medical Society with a paper, it occurred to me that I could hardly do
better than act on Mr. Holmes’s suggestion. But, before entering on the strict
subject of the communication which I have the honour to bring before you,
it will be advisable to make some prefatory remarks regarding the circum-
stances that led me to it. In March 1873, my friend Dr. Hector Cameron,
of Glasgow, recommended to my care, in the Edinburgh Infirmary, a case of
ununited fracture of the olecranon. Dr. Cameron had formerly been my house
surgeon in the Glasgow Royal Infirmary, and I had afterwards for several
years the great advantage of his assistance in private practice ; and he reminds
me that I had often expressed to him the opinion that the use of a metallic
suture, antiseptically applied, which we had employed in ununited fracture of
the shafts of the long bones, ought, in suitable cases, to be extended to the
olecranon and patella. The patient to whom I refer presented himself to
Dr. Cameron in the out-patient department of the infirmary ; and, as he had
not at that time beds in the institution, and therefore could not operate him-
self, he sent him to me. He was a man thirty-four years of age, who, five
months previously, had received a blow from a policeman’s baton on the left
elbow. This occasioned great swelling, which seems to have concealed the
true nature of the case from the medical man whom he first consulted. On
admission, there was a considerable interval between the olecranon and the
shaft of the bone ; and, although the limb was muscular, it was comparatively
helpless, as he could not extend the forearm at all without the aid of the other
hand. On the 28th of the month I made a longitudinal incision, exposing
the site of the fracture, and, at the same time, bringing into view the articular
surface of the humerus; and, having pared away the fibrous material from
454 AN ADDRESS ON THE TREATMENT OF
the fractured surfaces, I proceeded to drill the fragments, with a view to the
application of the suture. The fracture was oblique from before backwards,
as indicated by this diagram. I found no difficulty, with the proximal frag-
ment, in making the drill appear upon the fractured surface at a little distance
from the cartilage (see 6, Fig. 1), but with the other fragment the obliquity
of the position in which the drill had to be placed was so great that, instead
of the end of the drill emerging at the fractured surface, as I had intended,
I found it had entered into the substance of the humerus (d, Fig. 1). I there-
fore withdrew the drill, and substituted for it a needle (c d), passing the eyed
end in first. Then, with a gouge, I excavated an opening (e) upon the fractured
Fic, 1.
surface, opposite to the drill-hole (6) on the other surface, until the needle was
exposed. Withdrawing the needle, I introduced a silver wire in its place,
and I had no difficulty, by means of forceps passed into the excavation made
by the gouge, in drawing out the wire. I was then able to pass it on through
the other drilled opening, and thus the two fragments were brought into
apposition. The ends of the wire were twisted together and left projecting
at the wound. Healing took place without suppuration or fever, and the
wire was removed on the 19th of May, seven weeks after the operation. The
wound made for its extraction soon healed, and the patient returned to
Glasgow; and I afterwards had the satisfaction of learning that he was
wielding the hammer in an iron shipbuilding yard with his former energy.
I have had two other cases of ununited fracture of the olecranon; and,
as these are closely allied to the subject of my paper, I may refer briefly to
them. One was a man forty-five years of age, incapacitated for his occupation
FRACTURE OF THE PATELLA 455
as a plasterer by inability to extend the right elbow completely. The ununited
fracture of nine weeks’ standing was oblique laterally. It was treated as in
the last case; the operation presenting no difficulty. It was performed on
the 2oth of March, 1878. The wound healed without suppuration, but the wire
was not completely removed ; for, the loop having broken near the twist, the
twisted part was alone taken away, and the loop left behind. It never caused
any inconvenience, and he afterwards wrote to us from his home at Bristol
that he was able to follow his old employment.
The third case was that of a gentleman thirty-three years old, who had
consulted no fewer than eighteen surgeons on account of the weakness of his
left arm, caused by ununited fracture of the olecranon. I operated on the
28th of July, 1881, paring the broken surfaces as in the other cases, using
a chisel and hammer for the purpose ; and, having drilled the fragments with
a common bradawl, I brought them together with moderately stout silver
wire. In this case, however, I did not leave the ends of the wire projecting
from the wound; but, having given them one complete twist (or two half
twists), cut the ends off short, and hammered the twisted part down flat upon
the bone with this small hammer.
The advantage of this practice was strikingly exemplified by the difference
in the course of this case from its predecessors. Instead of keeping him under
treatment for several weeks until the wire could be removed, I was enabled
to allow him to return, fifteen days after the operation, to his home in Wales,
with a sound cicatrix ; and, trusting to the connecting loop of wire, permitted
him to use the elbow freely. I afterwards learned that he was able to drive
a four-in-hand as well as ever.
The practice of cutting the ends of the wire short, and hammering down
the twist upon the bone, is one to which I shall have to refer again in con-
nexion with my later cases of fracture of the patella. It is in every respect
an advantage. The hammering down of the twist renders it more secure than
if it is left projecting, to be moved by every shifting of the dressing, and
perhaps broken, as in the second of the cases just referred to. We also get
rid of a source of disturbance, and sometimes of considerable uneasiness, in the
wound. The time of healing is greatly shortened, and the knowledge that
the loop of wire securely holds the fragments in position allows the use of
the joint to be commenced much earlier than when we have only the organic
bond of union to trust to. The practice is also of the highest value in ununited
fracture of the shafts of the long bones. The thickness of the wire must be
proportioned to the force to which it is to be subjected. Tor the olecranon,
that which I have here is amply sufficient, only about one twenty-fifth of an
456 AN ADDRESS ON THE TREATMENT OF
inch in diameter. For the shaft of a femur of an adult male, a piece like this,
about one-tenth of an inch in thickness, which I have had specially prepared
with a view to a case of ununited fracture of the femur which we expect to
operate upon in the hospital this week, is requisite, in order to resist with
certainty the enormous force of the great muscles of the thigh. The pieces
of bone which I hold in my hand were removed, in August 1881, from a case
of badly united fracture of the femur. The patient was a gentleman from
Rio de Janeiro. The fracture had occurred about the junction between the
middle and upper thirds of the bone; and it had been so badly united that
the fragments overlapped very much, and also were at a considerable angle
with each other, so that the limb was extremely distorted, as well as much
shortened. Bloodlessness of the operation having been provided for by eleva-
tion of the limb and the application of an elastic tourniquet, I cut down from
the outer aspect of the thigh upon the seat of fracture. Then, with a periosteum-
detacher, I separated the soft parts from the place of junction of the fragments ;
and, in the next place, I went through the extremely laborious process of
cutting through the osseous union (which was of almost ivory hardness) parallel
to the axes of the two overlapping fragments. This having been at length
accomplished, and the soft parts still further detached, I found that I was
able not only to get the limb into a straight position, but also, by very moderate
extension, so to reduce the riding of the fragments that, by sawing off com-
paratively small portions, I was able to bring their extremities into apposition
and apply my suture. This was done with wire of about this same thickness.
The limb was put up at first with a long splint. I need not enter into details
regarding the after-treatment ; but I may say this, that he was a weakly man,
and it was some months before absolutely firm union was obtained. It would
have been extremely embarrassing to have had the ends of the wire sticking
out from the wound all that time. On the contrary, it was a very great
comfort to have no occasion to think about the wire; and ultimately he left
for South America, with a perfectly straight limb, almost of the same length
as the other, and, at the same time, with thoroughly firm union.
But to return to the immediate subject of my communication. Ever after
my first case of ununited fracture of the olecranon, I was on the look out for
a fracture of the patella to treat on the same principle. Dr. Cameron, how-
ever, anticipated me. In October 1876, being now full surgeon in the Glasgow
Infirmary, he admitted a man with transverse fracture of the patella. He
treated him, in the first instance, in the ordinary way, and dismissed him at
the end of eight weeks with a pretty short and strong ligamentous union.
Eleven days later, however, he reappeared, having ruptured the fibrous band
FRACTURE OF THE PATELLA 457
by a violent movement during a state of intoxication. The fragments were
then found widely separated. Dr. Cameron again treated him on ordinary
principles for eight weeks, at the end of which time the fragments were still
so widely apart, and the limb so feeble, that Dr. Cameron determined to cut
down and apply the wire suture antiseptically. This he did on the 5th of
March, 1877. On making a longitudinal incision, he exposed a condition of
the parts, of which, through his kindness, I am able to show you a sketch,
viz. a ligamentous union one inch in length, connecting pretty equal-sized
fragments, with nipple-like projections extending from their attenuated margins
much thinned by absorption. He cut away the fibrous material, and, having
pared the edges of the fragments, and drilled them in two situations with
a bradawl, he connected them with two sutures of stout silver wire (as shown
here in another drawing), the ends of the wires being left projecting at the
wound. At the same time, he introduced an independent drain into the joint.
The wound healed without suppuration or fever; and, though osseous union
was not obtained—which, as Dr. Cameron remarks in his report of the case,
was not to be wondered at, considering the thinned state of the surfaces—
yet he had the satisfaction of discharging the patient with close approxima-
tion of the fragments, and a thoroughly useful limb.
In October of the same year, 1877, a patient with transverse fracture of
the patella was admitted under my care in King’s College Hospital. He was
a man forty years of age, who, while riding on horseback, had his horse stumble
and fall. He was thrown over the horse’s head, falling on the right knee,
He could not rise, and was brought to the hospital. In the first instance,
I attempted with this patient to bring the upper fragment down, so that it
should be in contact with the lower. For this purpose I applied an apparatus,
into the details of which I need not enter further than to say that it was so
arranged that the upper fragment, by means of weights and pulleys, was drawn
down. Four days later, however, I found that there was still a quarter of
an inch interval between the fragments, and I suggested to the patient the
operation of cutting down and applying the wire suture. This, however, he
would not then consent to, and preferred returning home to be under the care
of his ordinary medical attendant. Eight days later, or fourteen days after
the accident, he was readmitted, expressing a wish to be operated upon. On
the 26th of October, I accordingly proceeded to operate, making a vertical
incision, about two inches in length, over the patella, exposing the fragments,
which were then one inch apart. My inability to bring down the upper
fragment into contact with the lower became explained when the parts were
exposed ; for there were found between the fragments extremely firm coagula,
LISTER II Hh
458 AN ADDRESS ON THE TREATMENT OF
with fibrous tissue, fascial and periosteal, mingled with them, constituting
so firm a mass as to make it quite impossible for the two fragments to be
brought into contact. The clots having been completely cleared away from
between the fragments and from the interior of the joint, I applied a common
bradawl in the middle line of the patella, drilling each fragment obliquely so
as to bring out the drill upon the broken surface a little distance from the
cartilage. Pretty stout silver wire was then passed through the drilled openings,
and the fragments thus strung upon it were pushed firmly home, and so brought
accurately into apposition. Before they were brought together, however, an
arrangement was made for the drainage of the joint. This was done on the
same principle in all the cases that I have to record, and I may therefore
describe the matter once for all. A pair of dressing-forceps, with the blades
closed, were introduced from the wound made into the anterior part of the
joint to the most dependent part of the outer aspect of the articulation. The
instrument was then forcibly thrust through the synovial membrane, the
fibrous capsule, and the fascia, until the point of the forceps was felt under
the skin. An incision was then made with a knife through the skin upon the
end of the dressing-forceps, so as to allow it to protrude. The blades of the
forceps were then expanded so as to enlarge the opening which they had made
in the deeper structures without risk of causing haemorrhage. The drain was
then seized in the forceps that protruded through the wound, and drawn into
the joint. The ends of the wire were now twisted together, and the twisted
ends brought out at the wound, which was closed with sutures and a small
drain inserted. I need hardly say that in this case, as in Dr. Cameron’s, anti-
septic treatment was employed throughout. It is unnecessary for me to enter
into details as to the progress of this case. We have here the temperature-
chart for as long as it was thought worth while to have it recorded, and you
will see that it indicates, after a little temporary disturbance immediately
after the operation, an entirely afebrile condition. The wounds healed with-
out any suppuration. At the end of eight weeks, the wire was removed by
an incision through the cicatrix. Eight days later, the wound made for the
removal of the wire had healed. At the end of ten weeks from the operation,
the patient was allowed to get up, and, though no passive motion had been
employed, he could move the limb freely through an angle of about thirty
degrees. Two days later he was discharged, and, unfortunately, nothing has
been heard of him since. I saw him once in a cart a few days after he was
dismissed, but I have not been able to learn any further tidings of him. This,
I believe, is the first instance of a recent case of fracture of the patella being
treated by wire-suture antiseptically applied.
FRACTURE OF THE PATELLA 459
My next case occurred two years later. William T-——, a coal-porter,
thirty-seven years of age, was admitted on the 13th of December, 1879. He was
a muscular man. The patient slipped on the gth of December, while carrying
a sack of coals, and felt something give way in one knee. On endeavouring
to rise, he found himself unable to do so. On admission into the hospital,
the right patella was found fractured transversely, the interval between the
fragments being about an inch. There was a considerable amount of effusion
into the joint. On the 15th of December, that is to say six days after the
accident, I proceeded to operate, making a longitudinal incision, as in the last
case, about two inches long, over the patella. The lips of the wound being
held apart with blunt hooks, a hole was drilled in each fragment in the median
line. Stout silver wire was passed, and secured by half-turns. BUR THIER Evie
DENCE REGARDING THE EFFECTS OF,
UPON THE SALUBRITY OF A SURGICAL
HOSPITAL (1870), 156.
Antiseptic system: not mere use of antiseptic
agent as a dressing, 51, 127
success of, impossible withook belief in germ
theory of putrefaction, 54.
INDEX TO VOLUME II 557
Antiseptic system (continued) :
ligature of external iliac artery on, 88.
immunity of author’s wards in Glasgow Royal
Infirmary from ordinary evils of surgical hos-
pitals under, 126; transformed into the
healthiest in the world, 500.
not mere use of an antiseptic, but management
to prevent putrefaction, 127.
loose style of ‘ giving the treatment a trial’
swells death-rate of compound fracture and
amputation, 127.
pyaemia, erysipelas, and hospital gangrene ban-
ished by, 134, 500.
illustrations of healthiness of wards resulting
from, even under unfavourable hygienic con-
ditions, 134.
importance of, in relation to hospital construc-
tion, 135.
removes malignant influence of impure atmo-
sphere in hospitals, 136.
author’s prediction as to improvement in healthi-
ness of surgical hospital when principle gene-
rally acted on, 131, 156.
letter from Professor Saxtorph of Copenhagen
giving his experience, 156.
does not owe its efficacy to any specific virtue
in agent employed, 157.
cannot be taught by rule of thumb, 157.
its principle is to render impossible existence of
living septic organism in affected part, 157.
must be based on germ theory of putrefaction,
157, 172; belief in this yet (1870) subject of
doubts in this country, 158.
causes of failure in application of, 172.
practical initiation in method necessary, 172.
its advantages illustrated by ligature of arteries
in their continuity, 188.
purifying effects of antiseptic system on atmo-
sphere of hospitals, 196, 197.
examples at Liverpool, 196; at Glasgow and
Edinburgh, 197.
expression of surprise at apathy in regard to it,
197.
good results said to be due to author’s personal
care, 264; really due to working on new
principle, 264.
surgery revolutionized by, 341.
hospitals no longer pest houses since its intro-
duction, 341.
operations previously prohibited successfully per-
formed under, 341.
gradual spread of, 364.
based on germ theory of putrefaction, 479.
exposition of, 495.
first appliances rude and needlessly complicated,
498.
improvements in, 498.
carbolic acid still (1896) best agent for purifying
skin around wound, 499.
results of, on healthiness of hospitals, 500.
in regard to treatment of wounds and enlarge-
ment of field of operative surgery, 501.
Antiseptic system of treatment, address on,
172.
causes interfering with general acceptance of,
172.
ANTISEPTIC TREATMENT, A METHOD OF,
APPLICABLE TO WOUNDED SOLDIERS
IN THE PRESENT WAR (1870), 161.
ANTISEPTIC TREATMENT IN SURGERY, A
CASE ILLUSTRATING THE PRESENT
ASPECT OF THE (1871), 165.
ANTISEPTIC TREATMENT: ADDRESS ON
THE EFFECT OF, UPON THE GENERAL
SALUBRITY OF SURGICAL HOSPITALS
(1875), 247.
Antiseptic treatment: obviates amputation after
compound fracture of limbs, 37.
and ligatures, 44.
in deligation of artery, 45.
effect of, on healthiness of hospitals, 45, 247;
illustrations of, on Continent, 247.
banished hospital gangrene, pyaemia and erysi-
pelas from author’s wards in Glasgow Royal
Infirmary, 45.
most signally successful in incised wounds, in
contused or lacerated wounds, compound frac-
tures and abscesses, 46.
based on germ theory, 46.
general principles of, 47.
requisites for success of, 51.
not merely the use of carbolic acid as a dressing, 51.
of acute necrosis, 65.
essential object of, not avoidance of suppuration
but prevention of putrefaction, 75.
illustrated by case of compound dislocation of
ankle with other injuries, 137.
details of dressing, 138, 139, 179.
intervals between dressings, 154.
causes of failure, 157, 158, 468, 470.
details of method, (1871) 179, (1890) 336.
promotes healing after division of cicatricial web
with subsequent elastic traction, 201.
does not operate by ‘excluding the air’ but
destroys vitality of floating ferments in atmo-
sphere, 205.
prevents but does not correct putrefaction, 216.
use of drainage tube in, 216, 217.
not invalidated by assumption that septic
material is not living organism but chemical
ferment, 219 (footnote).
value of, in treatment of wounds, compound
fractures, amputations, excisions,and abscesses
connected with bone disease, 248.
does not involve greater cleanliness, 254.
alleged long duration of patient’s stay in hospital
under, 255; this true of otherwise incurable
cases, 255.
makes healing more rapid in other cases, 255.
none but thoroughly aseptic instruments must
be used, 260.
instances of imperfection in carrying out, 250.
chief essential to success a conviction of presence
of septic matter in all objects in world around
us, 259.
objections to, in ovariotomy, 275; later success-
ful results of, 2706.
the two essential conditions of, 280.
refutation of charge that it leads to neglect of
general hygiene and consideration of consti-
tutional state of patient before operation,
291.
and the healthiness of wards, 291.
enlarges possibility of surgery in constitutional
as well as local direction, 292.
unexpected failures of, 293; ilustrative cases,
~93.
conditions of, 324.
558
Antiseptic treatment of abscess, 32.
of psoas abscess, carbolic acid does not enter
cavity, 186.
Antiseptic treatment in cases of amputation and
excision: causes of failure in, 131.
use of chloride of zinc as a part of, 131 (footnote).
Antiseptic treatment of compound fracture: early
cases of (leg), 3, 4, 5, 7-
(ulna), 6.
(humerus), 6.
(forearm), 9, I5I.
(lower limb), unvarying success of, 50.
block tin superseded in, 142.
(olecranon), I51.
(forearm), occurrence of putrefaction due to
small slough just beyond edge of lac-plaster,
T5%%
Antiseptic treatment of gunshot wound of femur,
76 (Cresswell in footnote).
Antiseptic treatment of senile gangrene, 195.
Antiseptic treatment of sinuses from caries of bone,
214.
Antiseptic treatment in surgery: fundamental
truth on which it is based now (1891) univer-
sally recognized, 340. -
original idea of, was exclusion of microbes from
wounds, 340.
Antiseptic treatment of ulcers, 1096.
illustrative cases, 196.
Antiseptic washing and irrigation unnecessary if
septic defilement of wound avoided, 337.
Antiseptics: difference in suppurative process
caused by, and that produced by putrefaction,
49.
their action on compound fracture, 40.
mode of avoiding suppuration from stimulating
action of, 50.
distinction between germicidal and inhibitory,
296, 359; established by Koch, 296; these
two properties not similarly proportioned in all,
359-
method of experimenting on properties of,
Sit.
Antiseptics, chemical: must be used whenever dis-
charge is considerable, 339.
prevention of contamination in operations and
dressing of wounds in absence of, 355.
Antiseptics and putrefactive products : both stimu-
late sores, but action of former is superficial,
whereas latter propagates itself, 149.
Antiseptics, volatile: disadvantages of, 294, 295.
Antitoxic substances produced by system, 513.
Antitoxin of diphtheria, 509, 510.
Antitoxin of snake poison, 510.
Antitoxin of tetanus, 509, 510.
Aorta: of one of larger animals, ligatures made of
(Barwell), 104.
Archigenes: used band encircling limb during am-
putation, 379.
his method of amputation used in seventeenth
century, 381; unsatisfactory results of method,
381.
Arm, amputation of, 399, 400.
Arterial dilatation: an early symptom of inflam-
mation in man, 528.
ee indirectly through nervous system,
528.
this Neat by removal of stitches of wound,
520.
INDEX TO VOLUME II
Arteries: deligation of, made safe by antisepsis, 45.
antisepticized ligature of animal tissue surrounds
vessel with living tissue and strengthens it at
obstructed part, 98.
division of internal and middle coats of, not
essential in ligature, 94, 106.
antiseptic ligature of, in their continuity, 269.
risks of non-antiseptic operation, 260.
Arteries, large : ligature of, in their continuity with
catgut, 87: deaths from secondary haemor-
rhage after, 102.
failure of operation owing to opening of channel
of vessels after, 102.
no haemorrhage after ligature of, during first
week, 190.
bleeding occurs owing to irritation of septic
ligature, 190.
if ligature not septic, no weakening of external
coat, 190.
Arteries: ligature of, in antiseptic system, 63, 86.
prevents decomposition of putrefactive germs in
thread, 63.
method first tested in horse, 64.
secondary haemorrhage after, caused by putre-
faction of tissue, 86.
secondary haemorrhage from, more frequent from
the distal than the cardiac end, 86 (footnote) ;
explanation of this fact, 86 (footnote).
death of external coat of, not in itself cause of
suppuration, 87.
ligature of, in their continuity under antiseptic
system, 188, 269.
risks of non-antiseptic operation, 2690.
Arteries, torsion of : comparatively seldom resorted
to by author, 183.
Artery, axillary: aneurysm of, Syme’s operation
for, 286, 287.
illustrates action of blood clot in prevention of
putrefaction, 287.
Artery, carotid: ligature of, for carotid aneurysm,
LO5-
Artery, carotid: in calf: ligature of, with threads
ofanimal tissue, 93; examination of parts after
death, 94.
effects of, on vessels, 97.
Artery, carotid: in horse, ligature of, with purse
silk steeped in saturated watery solution of
carbolic acid, 64.
Artery, common iliac: compression of, by wooden
cylinder introduced into rectum in amputation
of hip-joint, 415.
Artery, external iliac:
system, 88.
unsuccessful case of ligature of, with silk (Clutton),
102.
ligature of, for three aneurysms in one limb
(Pemberton), 111.
Artery, femoral: ligature’ of, with catgut for
popliteal aneurysm (six cases), 105, 188, 189.
ligature of, with antisepticized catgut for popli-
teal aneurysm; cases of, 188, 189, 218, 219,
220,°221.
ligature of, under carbolic spray, safer than cut
in skin without antiseptic treatment in ordi-
nary hospitals, 190.
Artery, external iliac:
(Annandale), 268.
wound healed without suppuration in fifteen
days, 269.
ligature of, on antiseptic
antiseptic ligature of
INDEX TO
Artery, innominate: ligature of, its fatality, 45.
this may be removed by antisepsis, 45.
Artery, temporal: traumatic arterio-venous aneu-
rysm of, ligature of vessels for, 105.
ARTICULAR DISEASE, REPORT OF SOME
CASES OF, OCCURRING IN MR. SYME’S
PRACTICE, .EXEMPLIFYING THE AD-
VANTAGES OF THE ACTUAL CAUTERY
(1854), 373+ P -
Asepsis of hands and instruments wiser than trust-
ing to most perfect cleanliness, 335.
Aseptic results: constancy of, with cyanide of
mercury and zinc dressing, 339.
obtained without exclusion of living atmospheric
organisms, 342.
means of obtaining constancy of, 349.
‘ Aseptin ’, 227.
boracic acid the active principle in, 227.
Aspirator: antiseptic use of, in evacuation of serous
and purulent collections, 223.
Aspirator, Dieulafoy's: 256; often becomes blocked
by lymph, 256.
Assistants at an operation :
care on part of, 344.
Association, British Medical: demonstrations of
antiseptic surgery before members of, 256.
Astley Cooper Prize: won by Wharton Jones for
essay on arrest of red corpuscles in capillaries
in inflammation, 518.
Atlas and axis: disease between, greatly benefited
by actual cautery (Syme), 376, 377.
Atmosphere: suppuration in wounds caused by
organisms in, 37.
filtered of contained particles by cotton wool,
176, 178.
not excluded, but floating ferments in, destroyed
by antiseptic dressing, 205.
destruction of floating ferments in, the essence
of antiseptic treatment, 205.
is it necessary to consider question of its conta-
mination ? 279.
pervaded by germs of minute organisms, 483.
microbes in, not to be dreaded in surgical prac-
tice, 499.
attenuated microbes in, not to be dreaded in
surgical practice, 499.
Atmosphere, antiseptic. See Antiseptic.
Atmosphere, gases in: no forms of life arise spon-
taneously in, 57.
Atmosphere in hospitals :
treatment, 136.
Atmosphere of surgical ward: vitiated by emana-
tions from sores, 135.
Atmospheric particles : low forms of life in, spring-
ing from pre-existing organisms, 60.
Attenuation of virus in fowl cholera the clue to
difference of virulence of same disease in
different epidemics, 504.
application of principle in production of 1mmu-
nity against anthrax, 504.
analogy with vaccination against small-pox, 504.
Axilla : division of both pectorals and free exposure
of, in removal of scirrhus of breast, 158. 4
cicatricial web of, divided and subjected to
elastic traction under antiseptic dressing, 210.
method of obtaining free access to, for removal
of glands in operating for cancer of breast, 272.
systematic clearance of contents of, in removal
of cancerous breast, 272.
need of scrupulous
purified by antiseptic
VOLUME II
559
Axilla (continued) :
drainage of, after clearing out in removal of
breast, 273.
Axillary abscess. See Abscess.
Axillary aneurysm. See Aneurysm.
Axillary artery. See Artery.
Axis and Atlas: disease between, greatly benefited
by actual cautery (Syme), 376, 377.
Bacillus anthracis: has very resisting spores, 351.
if killed in catgut ligatures does not get into
wounds, 351.
its size in comparison with influenza bacillus, 502.
Bacillus of diphtheria : discovered by Loeffler, 508.
Bacillus, comma. See Cholera.
Bacillus, hay: has exceedingly resisting spores,
351; does no harm in wounds, 351.
Bacillus of influenza: discovered by Pfeiffer, 502.
its minuteness, 502.
Bacillus pyocyaneus: killed by carbolic acid, 341,
242
destroyed by weak sublimate solutions, 344.
Bacillus of tetanus, 508.
Bacillus of tubercle: always present in pyogenic
membrane of chronic abscess, 347.
Yersin’s experiments on agents having germicidal
action upon, 351.
killed more quickly by carbolic acid than by
corrosive sublimate, 352.
Crookshank’s experiments on, as found in phthi-
sical sputum, 352.
destructive power of carbolic acid on,
need not be feared in surgical work if
steeped in strong carbolic lotion, 353.
discovered by Koch, 502.
Bacteria: not always present in abscess, 216.
in water, number and variety of, 226, 277.
after wide diffusion by means of water, incapable
of developing in undiluted healthy serum, 278;
suggested explanation of fact, 278, 270.
diffusion of chemically irritating products of,
beyond limits of septic process, 284.
cannot grow on mucus of healthy urethra, 288.
unable to develop in concentrated organic solu-
tions (Naegeli in footnote), 290.
develop less easily in organic solution in propor-
tion to its concentration, 355.
action of iodoform on, 356; has little influence
on growth of, outside body, 356; produces
chemical changes in toxins of, 3506.
Bacteria, pathogenic: a term introduced by Ger-
man pathologists, 289 (footnote).
normal blood serum not favourable soil for
growth of, when not in too strong a dose,
350.
Bacteria: ‘plate culture’ of,
Koch, 502.
description of method, 503.
its importance recognized by Pasteur, 503.
Bacteria, putrefactive: resistance of organizing
blood clot or lymph to, 286.
Bacteria, septic: development of, prevented by
blood clot, 280; development of, prevented
by healthy living tissues, 280.
Bacteria, spore-bearing: resist all known germi-
cidal agents that could be used in operation,
341.
Bacteria, sporeless :
342.
demonstrated by
killed by carbolic acid, 341,
560
Bacteria: toxins of, in false membrane of diph-
theria, 507, 508.
Bacteric development: caused in uncontaminated
milk by addition of one-hundredth of a minim
of water, 277.
results of experiment differ according to season,
277 (footnote).
prevented by adhesive inflammation of perito-
neum, 286 (and footnote).
power of living tissues to oppose, 288.
prevented by organizing blood clot, 288.
Bacterium lactis : a single one detached from others
by diffusion by means of water as sure to pro-
duce its kind as a million taken from souring
milk, 278.
Bandage, elastic: method of applying to limb for
amputation at hip joint, 415.
Bandage, elastic: Esmarch’s, 394, 395, 390.
v. Langenbeck’s, 395, 396.
Bandages: method of making antiseptic by charg-
ing with double cyanide, 363.
Bantock, G. Granville: his successful ovariotomies,
335:
does not prepare ligatures antiseptically, 335.
uses strong silk twist for tying pedicle, 335.
success in abdominal surgery without antiseptic
means a stumbling block to some, 335.
washes out peritoneum with water, 335.
uses sponges wrung out of sulphurous acid for
cleansing peritoneum, 335.
Bardeleben: results of antiseptic treatment in
Charité Hospital, Berlin, 252.
use of unprepared gauze soaked in watery solu-
tion of carbolic acid, 252.
Barker, Arthur: ‘flushing gouge’ suggested by,
346, 347 (footnote).
Barwell: use of ligatures made of aorta of larger
animals, 104.
Behring, v.: resistance of Staphylococcus pyogenes
aureus to germicidal action of bichloride of
mercury, 343.
staphylococci killed by carbolic acid, 344.
toxins of bacteria altered chemically and ren-
dered harmless by iodoform, 356; his experi-
ments on this point, 356.
discovery of antitoxic serum, 509; its application
in tetanus and diphtheria, 510; successful in
latter case, 510; his hope that antitoxin will
reduce mortality from diphtheria to 5 per cent.,
512; probability that it will be realized, 512.
Bell, Benjamin (Edinburgh), ‘ circular’ method of
amputation, 383.
Benzene vapour: diffused through cotton wool as
an antiseptic dressing, 176.
Berlin: antiseptic treatment in Charité Hospital, 252.
Bernard: his testimony as to beneficial effect of
antiseptic system on healthiness of wards in
Naval Hospital, Plymouth 107.
Bernard, Claude: induction of turgescence of
vessels of ear by section of sympathetic in
neck, 529.
Bickersteth : method of treating ununited fracture
by drills, 11.
Biniodide of mercury. See Mercury.
Bishop: his observation that dispensing with
macintosh in antiseptic gauze dressing greatly
lessens foul smell, 188.
Block tin: no suppuration in healthy granulating
wound covered by, 40.
INDEX ‘TO VOLUME «II
Block tin (continued) :
use of, to protect exposed tissue from stimulating
action of antiseptic dressing, 78, 79, 80.
superseded in antiseptic dressing of compound
fracture, 142.
Blood: acted on by carbolic acid remains suscep-
tible to organization, 8, 53; similar effect on,
of chloride of zinc, 53.
no decomposition of, when effused into pleura in
puncture of lung from simple fracture of rib, 60.
action of corrosive sublimate on albumen of, 299.
experiments on effects of corrosive sublimate on,
300.
in “purified bottle and placed in stove at body
temperature remains unaltered, 350.
becomes putrid on introduction of needle con-
taminated with putrefied blood, 350.
introduction of bacteria diffused in sterilized
water does not cause putrefaction, 350.
researches on corpuscular elements concerned in
supplying to plasma materials for formation
of fibrine, 538 (footnote).
Blood-clot : and carbolic acid fused together into
living mass, I1.
‘organization’ of, 118, 153; consists of infiltra-
tion with newly formed cells, 118.
vascularization of, in healing under antiseptic
treatment, 153.
organizing in wound antiseptically treated, how
it differs from granulations, 265, 267.
inferred to possess special power of preventing
development of septic bacteria, 280.
its power of resistance to development of micro-
organisms, 281 (and footnote), 285 (and footnote).
experiments on putrefaction of, in living body
(donkey), 282, 283.
in living vein, its liability to suppuration under
septic influence, 283.
no new growth of corpuscles in outside body, 284.
action of, in preventing putrefaction explains
union by first intention without antisepsis, 287.
formation of epidermis on, under sublimate wool
dressing, 298.
does not contract when blood drawn under
antiseptic precautions, 300; this a ‘ perfect
mystery’, 300.
antibacteric influence of, 334; explained by pha-
gocyte theory, 334. :
suppuration of, its relation to pyaemia, 541.
Blood-clot, organized: production of secondary
mass when first is insufficient, 266.
in wounds antiseptically treated: how it differs
from granulations, 265, 267.
in wounds, 267.
development of cells of new formation in, first
observed by author, 285 (footnote) ; observa-
tions on subject by Tillmanns and others, 285 ;
cell development may go on to suppuration,
285.
its power of resisting development of putre-
factive bacteria, 286.
prevents bacteric development, 288.
under superficial layer of coagulum without
suppuration, 291.
Blood, coagulation of: in different species of
animals, 521.
its importance in surgery, 535.
B. W. Richardson’s Astley Cooper Prize Essay
on, 535-
INDEX TO VOLUME II
Blood, coagulation of (continued) :
experiments by author on, 535 (and footnote),
536, 537, 538.
action of solids on, 537.
healthy living tissue has not aggregating pro-
perty of solids, 537.
brought about by operation of noxious agents in
tissues concerned, 539.
See also Buffy Coat.
Blood corpuscles. See Corpuscles.
Blood, decomposition of: cause of suppuration in
wounds, CVE
cause of local inflammation and febrile disturb-
ance after injuries, 37.
Blood, extravasated : seat of suppuration without
external wound, 21.
Blood, human: shows buffy coat in inflammatory
States, 521.
Blood: putrefaction produced in, by mixture of
putrid blood with boiled water, 278.
Blood, putrid: diluted with boiled water added to
serum Causes no putrefaction or development
of micro-organisms, 278.
Blood, stasis of: in web of frog’s foot and in
bat’s wing as result of irritating applications,
Blo:
in inflammation, Wharton Jones’s researches on,
518; author’s investigations on, 518, 519, 520;
due to tendency of corpuscles to accumulate
in vessels of irritated area, 522.
Blood, uncontaminated: no putrefactive change
caused by exposure to air or introduction of
dust, 279.
Bloodless method of operation, 213; Esmarch’s
india-rubber tube substituted for tourniquet,
213 (footnote).
Bone: absorption of chips of, produced in anti-
septic operation for ununited fracture of neck
of femur, 193.
Bone, caries of. See caries.
Bone, dead: absorption of, by granulation tissue
in case of compound fracture of leg treated
antiseptically, 16, 66, 148.
free from decomposition, absorbed by granula-
tions, 40.
soaked with putrid pus induces suppuration in
vicinity, 40.
in acute necrosis of tibia, 66.
absorption of, by granulations when there is no
putrefaction, 117.
replaced by living osseous tissue under antiseptic
dressing, 497.
Bone killed by inflammation does not, under
antiseptic treatment, induce suppuration, 66.
Bone pliers: Liston’s, use of, in amputation,
393+ a ae aint
Bonn: effects of antiseptic treatment in clinical
hospital at, 253.
Boracic acid: antiseptic properties of, 227.
used in onychia, 227; in pruritus ani, 228;
in eczema, 228; in recent abrasions, 232.
interferes with cicatrization less than ‘carbolic
acid, 2209.
particularly useful for skin grafting, 230.
Boracic acid lotion: use of sponges soaked in, for
wounds communicating with mouth, 245.
Boracic acid ointment: preparation of, 240.
use of, after excision of rodent ulcer, 240, 244 ;
use of, after excision of joint with sinuses where
5601
chloride of zinc has failed to eradicate septic
condition, 246.
Boracic lint : ‘mode of preparation, 229.
use of, in treatment of ulcers, 229.
details of dressing, 229, 230.
as moist application in treatment of foul ulcers,
232.
in treatment of deep burns, 233.
illustrative cases, 233.
as moist dressing after operations on penis, 23
234, 235, 236, 237, 238, 239.
in hypospadias, 236, 237, 238.
Ge
~
in defective meatus, 238, 239, 240.
Breast. See Mamma.
Bricke (Vienna): his observation that blood
remains fluid in turtle’s heart long after
removal from body, 537 (footnote).
Bruns (Tubingen): his paper Fort mit dem Spray,
280 (and footnote).
advocates carbolic irrigation in place of spray,
280 (footnote).
Buchanan, Andrew: coagulation of hydrocele
fluid by addition of serum of coagulated
blood, 257.
mechanism of coagulation of blood, 538.
Buchanan, George: compound fracture of leg
treated with pure carbolic acid, 28.
case of compound dislocation of ankle treated
antiseptically, 141.
Buffy coat: in coagulated blood of horse,
in donkey, 521.
none in cow, 521.
not due to slowness of coagulation, 521.
in human blood in coagulation, 521.
in anaemia, 521 (and footnote).
Burns: boracic lint in treatment of, 233.
521.
Bursa patellae: chronic inflammation of, treated
antiseptically, 221.
inflamed, painless puncture of, under ether
spray, 222 (footnote).
inflammation kept up in, by presence of fluid in
SAG 0223.
Bursitis patellae: antiseptic treatment of, 221.
description of inflammatory process in, 223.
Busch, v.: effects of aaitice Puc treatment in
clinical hospital, Bonn, 253.
‘Button suture ’, description of, 241.
use of,
241, 242; after removal of breast, 273.
Caesarean section: death caused by giving way of
knots of catgut ligature in intern¢ il-wound, Io.
Cagniard- Latour: discov ery of yeast plant, 479, 493.
Calf: ligature of carotid artery of, on antiseptic
system with threads of animal tissue, 93.
examination of parts after death, 94.
Calf lymph: should be used in vaccination, 506.
Calmette: antitoxin protecting against snake
poison, 510.
Cameron, A.: cases of compound fracture of ulna
treated with carbolized oil, 27.
Cameron, Hector C.: carbolic acid in treatment
of contused and lacerated wound of hand, 44.
case of penetrating wound of thorax and
abdomen, OI.
case of psoas abscess successfully treated by
antiseptic method, 187.
contribution on zinco-cy anide of mercury dressing
by author to his Dr. James Watson Lectures,
Glasgow,
329, 305.
562
Cameron, Hector C. (continued):
letter to (1906), on some points in history of
antiseptic surgery, 365.
extract from lecture by, relating experiment of
Lord Lister (1894), showing avidity with which
carbolic acid seizes upon epidermic tissues, 370
(and footnote), 371 (footnote).
case of ununited fracture of olecranon sent to
author for wiring, 453.
case of transverse fracture of patella treated by
wiring, 456, 457.
use of continued wire suture in fractured patella,
474,
Cancer: application of chloride of zinc to wound
after operation to prevent recurrence (Camp-
bell de Morgan), 51.
Cancer, epithelial: of tongue: operation on, by
Syme’s method, 53.
Cancer of maxillary bones :
after operation for, 53.
Cancer of penis: boracic
operation for, 235.
Cancer, scirrhous, of breast: removed with
division of pectoral muscles and free exposure
of axilla under antisepsis, 158.
Carbolated cotton wool. See Cotton.
Carbolic acid: author struck by effect of, on
sewage of Carlisle (1864), 3.
destroys entozoa infesting cattle, 3.
glacial or crystalline, and fluid, 3 (footnote).
preventive of suppuration, 3.
advantages of, in dressing wounds, 4; details of
method, 4.
in compound fracture cases, 4, 5, 6, 7, 28, 20,
38, 41, 341.
improvement in mode of use, by protecting crust
with metallic covering instead of oiled silk or
gutta percha, 6.
in extravasated blood, removed by absorption, 9.
causing suppuration, 8, II, 40, 147.
and blood-clot fused together into living mass,
Eile
tends to check cicatrization, 14.
a painless caustic, 15.
in compound fracture of femur, 18.
in compound fracture of leg, 28, 29, 38.
in treatment of abscess, 32.
its destructive power on low forms of life, 37.
though preventing decomposition, may induce
suppuration by acting as chemical stimulus,
40, 147.
stimulates only surface to which it is applied, 41.
discharge weakens by dilution, 41.
and decompositon, different effects of, in regard
to suppuration, 41.
in compound fracture of humerus, 41.
objection to injecting into unopened abscess, 42.
in treatment of simple incised wound, 44.
use of, to destroy germs during operations, 44.
generally used by author in antiseptic treatment,
Bae
new as external therapeutic agent to most
British surgeons, 51.
not in itself a specific, 51.
importance of its employment according to
author’s system appreciated by Continental
surgeons, 51.
other disinfectants may have same effect if
used on antiseptic principles, 52.
chloride of zinc used
lint as dressing after
INDEX TO VOLUME II
Carbolic acid (continued) :
superior to chloride of zinc except when efficient
external antiseptic dressing cannot be main-
tained, 53.
superior to other antiseptic agents in ordinary
cases, 54.
confirmation of advantages possessed by, 54.
a local anaesthetic, 54.
free application of, to large wounds cause of
obstinate vomiting, 84.
being a stimulating substance, induces suppura-
tion by long continued action on tissues, 147.
use of, in female complaints, 213.
antiseptic properties of, 257.
does not stop suppuration by any specific agency,
265.
used in antiseptic treatment of compound
fractures, 341.
unsuitable for application to incised wounds
owing to caustic properties, 341.
kills sporeless bacteria, 341, 342.
action of, upon micrococci more uniform than
that of corrosive sublimate, 344.
not hindered in its action by albuminoid sub-
stances in same degree as sublimate, 344.
for some time displaced by corrosive sublimate,
Bisa
corrosive sublimate
purposes, 351.
destructive power of, on tubercle bacilli, 352,
its use for purification of sponges, instruments,
hands, and skin, 353, 354.
penetrates epidermis better
sublimate, 354.
wrongly described as insoluble in water, 367.
watery solution a powerful antiseptic, 367 ; recog-
nition of this led to application of antiseptic
principle to surgery in general, 368.
explanation of its germicidal power, 368.
special attraction of, for epidermis, 368; experi-
ments showing this, 370, 371.
detergent property of, 369, 370; illustrated in
case of operation for large ventral hernia, 369.
its deodorizing effect on sewage, 497; this led
author to apply it in compound fractures, 497.
Carbolic acid with chromic acid: in preparation of
catgut ligature, 112; details of method, 113.
Carbolic acid with lint: forms crust with blood
which is replaced by living tissue, 365.
Carbolic acid, diluted with water: its uses for
surgical purposes, 498.
Carbolic acid, diluted with oil: in treatment of
compound fracture, 4, 26, 27.
Carbolic acid, dissolved in olive oil: cloth dipped
in, aS a dressing, 68, 213.
not reliable, 68, 70.
case of compound fracture successfully treated
with, 68.
lint soaked in, may lose antiseptic property, 70;
constant application of fresh oil obviates this,
70 (footnote); useful in certain situations such
as perineum, 70 (footnote); reliable in cases
where discharge is trifling, 70 (footnote).
linseed oil objectionable, 213 (footnote).
Carbolic acid gauze. See Gauze.
Carbolic acid, soluble in water and fixed oils, 67.
impurities interfere with its solubility in water,
7 fs
J?
inferior to, for surgical
than corrosive
INDEX
Carbolic acid (continued) :
and products of putrefaction react chemically on
each other, 70; latter, if in sufficient quantity,
may neutralize former, 70; example of this, 70.
held with great tenacity by lac, 77.
rapidly parted with by india-rubber, 77 (footnote).
has no mysterious virtue apart from antiseptic
property, 168.
strong solution of, as a wash for raw surfaces, 180.
interferes with cicatrization of wound if it acts
directly thereon, 184; therefore ‘ protective’
necessary, 184.
Carbolic acid lotion: may be aesthetically dirty
but surgically pure, 261.
Carbolic acid solution: gradual
strength of, 181.
Carbolic acid spray. See Spray.
Carbolic acid, undiluted : a powerful caustic, 498.
therefore unsuitable for wounds made by surgeon,
498.
Carbolic acid: 1 in § parts of spirits of wine for
washing wound in compound fracture seen
after several hours, 206 (footnote).
Carbolic acid, 1 in 20 watery solution of: in treat-
ment of fetid suppurating wound of palm, 83.
in treatment of interior of wound in compound
fracture, 84, 85.
advantages of, compared with undiluted acid, 84.
for purifying part to be operated on, dirty
instruments, and sponges, and for washing
accidental wounds, 206.
Carbolic acid: 1 in 40 lotion recommended (1875)
for washing and guarding wounds in changing
dressings, 206.
Carbolic acid, watery solution :
catgut ligature, 112.
strong watery solution of, in treatment of
compound dislocation of ankle, 138.
mixture of spirit of wine or glycerine with,
weakens its antiputrefactive action, 138.
compared with carbolic putty, 368.
Carbolic acid paste: in treatment of compound
fracture, 28.
in dressing of large wounds, 38.
improvements in mode of use, 37.
in treatment of compound fracture, 309.
in treatment of abscess, 43.
See also Paste.
See also Putty.
Carbolic acid putty: as a dressing, 33, 368
4n treatment of compound fracture, 36.
in treatment of incised wounds, 36.
compared with watery solution, 368.
Carbolic acid: strong solution of, as a wash for
raw surfaces, 180.
Carbolic acid vapour :
wool as an antiseptic dressin
Carbolic dressings, 67.
respective advantages of
solutions in, 67.
trials of, in various forms, 68.
in paste of boiled linseed oil and whitening, 68.
in lint dipped in the acid dissolved in olive oil,
68.
in various emplastra, 71.
in paraffin cerate, 71.
in soap plaster (Watson), 71.
in emplastrum plumbi with beeswax, 71.
in lac plaster, 71 (footnote).
reduction in
in preparation of
diffused through cotton
g, 176.
watery and oily
TO VOLUME II
| Carbolic lotion:
563
should not be used in case of
wound communicating with mouth, 245.
Carbolic oil : in preparation of catgut ligature, 112.
no danger of over-preparation by this method,
I1I2.
Carbolized gauze. See Gauze.
Carbolized glycerine: as dressing in abscess near
rectum, 215 (footnote).
Carbolized lac. See Lac.
Carbolized oil: as lubricant for instruments intro-
duced into bladder, 212; use of, for this pur-
pose first suggested ee Rolleston, 212 (footnote) ;
for vaginal specula, 213.
use of, in abscess beside rectum, 215.
glycerine substitute for oil as vehicle of carbolic
in dressing of abscess near rectum, 215 (foot-
note).
compared with watery solution, 368.
Carbolized silk sutures: preparation of, 219 (foot-
note).
Carbolized sponge. See Sponge.
Carcinoma. See Cancer.
Carden (Worcester): advantages of anterior flap
in amputation, 387.
his method of amputation at knee,
advantages, 390.
amputation through condyles of femur, 409, 410,
4Il.
author’s modification of, 410.
Caries: excision of wrist for, 199, 417
description of parts removed, 199.
result of case seven years later, 199.
Caries of ankle: antiseptic treatment of abscess
connected with, 35.
Caries of bone: the suppurative stage of inflamma-
tion in a weak tissue, 35.
tends to spontaneous cure on withdrawal of
irritation, 35, 43.
opening of ‘abscesses connected with, 35.
element of incurability eliminated by antiseptic
treatment, 48.
antiseptic treatment of, in sinuses, 214.
scraping out of sinuses with sharp spoon, 251.
Caries of bones of foot: operation for, 213.
antiseptic treatment of, 214, 215.
illustrative cases, 215.
Caries of elbow: antiseptic treatment of abscess
connected with, 35.
Caries of hip: antiseptic treatment of abscess con-
nected with, 35.
Caries of joints with sinuses :
ointment in, 246.
Caries of knee: antiseptic treatment of abscess
connected with, 35.
Caries of vertebrae, antiseptic treatment of abscess
connected with, 35.
Carlisle: effect of carbolic acid on sewage of, 3.
Carotid artery. See Artery
Carpus. See Wrist.
Catch forceps, Liston’s :
393.
CATGUT: NOTE ON PREPARATION OF,
FOR SURGICAL PURPOSES (1908), 119.
Catgut: manufactured from small intestine of
sheep, 84, 107; details of process as carried
out in manutacture, 107.
nine successful cases of ligature of arteries with,
105.
importance of
389; its
use of boracic acid
use of, in an amputation,
‘seasoning’ of, by time, 100.
564
Catgut (continued) :
example of this in case of fiddle strings, 109.
conditions required to make it reliable for surgical
purposes, 110. —
method of preparing, IIo.
overprepared by chromic acid, disadvantages of,
eters
prepared with tannic acid, I11.
conditions on which its strength depends, 113.
how the surgeon may prepare it himself, 114.
breaking strain of, when thus prepared, 114;
method of testing this, 114 (footnote).
prepared by new method, experiments as to
strength of, 115.
its behaviour among tissues, 115.
manner in which it is absorbed, 116.
action of living tissues on, 117.
improperly prepared, quickly softened by infil-
tration of young growing cells, 117.
when properly prepared, slowly eroded, 117.
sulphate of chromium with addition of corrosive
sublimate for preparation of, 119.
may be kept a long time in prepared fluid of oil,
carbolic acid, and water without spoiling, 270.
properly prepared less rapidly absorbed than that
which has been for a shorter time steeped in
prepared fluid, 271.
should be tested by surgeon before use in ligature
of artery in its continuity, 271; mode of test-
ine, 270
different kinds of, 271 (footnote).
method of preparing for surgical use, 271 (foo?-
note).
Catgut, chromic: directions for preparation of, 120.
prepared according to these directions remains
antiseptic for indefinite period, 120.
experiments showing this, 120.
Catgut drain. See Drain.
Catgut infusion : prepared with chromium sulphate
}-| and corrosive sublimate, experiments showing
m4 germicidal property, I21, 122.
Catgut, prepared: changes in, 99.
how it should be used, 100.
to be placed in 1 in 20 solution of carbolic acid
before operation, 122; suppuration sometimes
due to neglect of this precaution, 122.
Catgut, asepticized: used in a calf, 93.
CATGUT LIGATURE, AN ADDRESS ON (1881),
IOI.
Catgut ligature: how made antiseptic, 84, 99, 182.
different thicknesses of, 85.
how to keep supply ready for use, 85.
mode of preparing and rendering antiseptic, 99.
its advantages not limited to wounds in which
putrefaction has been avoided, 101.
does not come away like sloughs in wounds which
are the seat of septic suppuration, 101.
death caused by knots giving way in internal
wound after Caesarean section, IOI.
abandoned by many surgeons for silk, 102.
results not always satisfactory, 102 ; an instance
of this (Clutton), 102.
advantages of, 104, 497, 498.
must be specially prepared for surgical use, 104.
cases of large arteries tied in their continuity with,
105, 188.
used in tying carotid artery for aneurysm, 105.
nine successful cases of ligature of arteries, 105.
mode of applying, 106.
INDEX TO VOLUME II
Catgut ligature (continued) :
advantage of division of internal and middle
coats of artery in, 106.
reasons of author’s success with, 106.
long time needed in preparation of, 106; disad-
vantages of this, 106.
untrustworthiness of insufficiently prepared liga-
tures, 107; instance of this, 107.
slipping of insufficiently prepared, 107.
experiments to devise means of shortening time
required for preparation, 107.
new method of preparing, 112.
used to tie carotid artery of calf: demonstration
of replacement of old tissue by new living
tissue, 118.
conditions to be fulfilled for surgical use, 119.
must not be too quickly absorbed, 110, 119.
antiseptic, use of in operations, 182.
testing, 183.
held in reef knot with ends cut short, a perfect
haemostatic, 183.
in deligation of arteries in their continuity, 188.
will cause secondary haemorrhage unless putre-
faction in wound avoided, 190.
application of, in operation for irreducible hernia,
191; two illustrative cases, I9I.
anthrax caused by, 341 (v. Volkmann in footnote).
idea of, suggested by replacement of crust of
carbolic acid lint and blood by living tissue,
365.
Catgut ligature, antiseptic :
tions, 182.
testing, 183.
preparation of, 269.
importance of water in oily mixture in which it
is steeped, 269.
untrustworthiness of method before described,
270.
right method of preparing, 270.
Catgut ligature, aseptic: experiments show to be
replaced by ring of living tissue around vessels,
190.
use of, for arrest of haemorrhage from wounded
vein, 271 ; illustrative cases, 271, 272, 273, 274.
Catgut ligature, chromicized: applied to external
iliac artery, III.
found unaltered in granulations two months
after operation, III.
use of, recommended, 118.
directions for preparation of, 120; prepared ac-
cording to these directions remains antiseptic
for indefinite period, 120; experiments showing
this, 120.
Catgut ligatures, unasepticized: tried and found
unsatisfactory, 92.
Catgut, ‘organization’ of: does not mean that
substance comes to life again, but that old
tissue is replaced by new, 118.
Catgut sutures: conditions they should fulfil for
surgical use, 119.
Cauterium cultellare (red hot knife) in amputation :
recommended by Fabricius Hildanus, 380
(and footnote).
Cautery: use of, recommended by Celsus for
arrest of haemorrhage, 379 (footnote); pre-
ferred by mediaeval surgeons to ligature for
control of haemorrhage in amputations, 380.
Cautery, actual : advantages of, in articular disease,
37 3+
use Of, in opera-
INDEX TO
Cautery, actual (continued) :
cure of omalgia by, 373, 374.
cure of disease of shoulder-joint by, 374, 375.
cure of disease of wrist-joint by, 375, 3706.
disease between atlas and axis benefited by, 376,
Sie eae >.
counter-irritation with,
Britain by Syme, 377.
introduced into Great
Cells; proliferation of, as cause of pus formation,
SA2.
Celsus: his teaching on amputation, 378.
recommended removal of limb through healthy
tissues, 378.
use of ligature for arrest of haemorrhage after
amputation, 370.
on arrest of haemorrhage, 379 (footnote).
on means of arrest of haemorrhage, 379 (footnote).
aimed at primary union after amputation, 379
(footnote).
neglect of his method of amputation and of
treating wounds in Middle Ages, 379 (footnote).
his method of amputation revived by Louis,
382.
Cement, antiseptic: attempts to obtain, 77.
Cerebro-spinal axis: shown by experiments to
preside over contractions of arteries of foot in
frog, 529, 530.
Chassaignac : caoutchouc drainage tube, 443.
Charité Hospital, Berlin: since introduction of
antiseptic treatment pyaemia abolished, hos-
pital gangrene uncommon and erysipelas very
rare and mild,
Charpie made of old rags: made antiseptic, 306.
Chavasse : report on result of case in which patella
was wired for recent transverse fracture, 463.
Cheatle, G. Lenthal: granulating wounds in South
Africa behaved better with cyanide dressing
than with iodoform, 331 (footnote).
Cheese-mites do not originate spontaneously, 482,
483.
Cheselden: amputation by
(and footnote).
Chest: external wound penetrating,
purative pleurisy, 3.
Chevreul: experiment illustrating germ theory of
putrefaction, 54; Pasteur’s experiments on
organisms in air, with flask with bent neck,
attributed by him to, 485 (footnote).
Cheyne, W. Watson: species of micrococci shown
by, to occur very frequently in cases treated
antiseptically without any interference with
aseptic progress, 103.
action of tissues on catgut used as a drain, 116.
no organisms found in discharges of carbolic acid
gauze dressing changed daily, 294.
experiments on germicidal power of cyanide of
mercury, 313.
Chiene, John: observation of secondary blood clot
in hollow wound becoming organized on top
of first, 268; catgut drain, 444.
Chloride of aluminium. See Aluminium,
Chloride of zinc. See Zinc.
Chlorine gas: saturated solution of, applied to
wound which had become seat of putrefaction,
155.
diffused through cotton wool as an antiseptic
dressing, 176.
Chlorine water :
surfaces, 180.
‘double incision ’, 382
causes sup-
as an antiseptic wash for raw
VOLUME II
565
Chloroform as anaesthetic: introduced by J. Y.
Simpson, 492.
rightly administered safer than ether, 492; Edin-
burgh method of administering, 431 (and foot-
note); amputation of thigh under, witnessed
by author, 491.
Cholera microbe. See Microbe.
Choléra des poules, 504.
Chopart’s amputation through tarsus, 404.
Chromic acid: catgut prepared with, 111.
with carbolic acid in preparation of catgut liga-
ture, 112; details of method, 113.
Chromic catgut. See Catgut.
Chromium, sulphate of: in preparation of catgut,
ITO.
its untrustworthiness as a germicide removed by
addition of corrosive sublimate, 119.
variations in quality of, 1109.
how this is remedied, 119.
great care required in preparation and preserva-
tion of, 119 (footnote).
Cicatrix : contracted, deformity from, treated anti-
septically, 200.
contraction of, counteracted by elastic traction
with india rubber, 201.
Cicatrization : with suppuration beneath a piece of
tin—a novel mode of healing by scabbing, 82.
interfered with by carbolic acid acting directly
on wound, 184; therefore ‘protective ’ neces-
sary, #84.
without granulation under antiseptic dressing,
265.
Cilia on epithelium of frog’s tongue:
motion of, 527, Sai
effect of heat on, 527, 528.
Ciliated cells on surface of frog’s tongue, 512
effects of stimulation and irritation on “them,
512.
Ciliated epithelium cells: vital functions suspended
in, by injurious agencies, 528.
Cleanliness: distinction between antisepsis and,
254.
Cleanliness, surgical and aesthetic:
between, 291.
Clinical surgery. See Surgery.
Clutton: unsuccessful case of ligature of external
iliac artery with silk under antiseptic system,
102.
Coats, James: and antiseptic treatment, 128
compound dislocation of ankle treated antisep-
tically, 141.
Coats, Joseph: calls attention to fact that carbolic
acid does not pass so readily through oiled
silk as through gutta percha, 145.
Cohnheim: emigration of leucocytes in inflamma-
tion, 333, 334-
his observation of passage of white corpuscles
through walls of vessels into surrounding
tissues in inflammatory conditions,
emigration of leucocytes, 542.
not the exclusive mode of pus formation, 542.
Colon : vibrios in abscess in vicinity of, 42 (footnote).
‘Comma bacillus *, 503.
COMPOUND DISLOCATION OF ANKLE, WITH
OTHER INJURIES. REMARKS ON A
independent
distinction
513.
CASE OF, ILLUSTRATING THE ANTI-
SEPTIC SYSTEM OF TREATMENT (1870),
137.
Compound dislocation, See Dislocation.
566
Compound fracture. See Fracture.
Congestion, active: caused by stitches, illustrates
influence of nervous system, 528.
phenomena of, studied in frog’s web, 529.
experimental study of process in frog, 528, 529,
5 30.
Congestion, inflammatory: may be produced by
nervous agency, 531.
experiments proving this, 531, 532.
illustrative case in man, 532.
Contused wounds. See Wounds.
Cooper, Astley: separation of metatarsus from
tarsus, 404.
his opinion that blood tends spontaneously to
coagulate and is kept fluid by action of living
vessels, 536, 537.
Copenhagen: effect of antiseptic treatment on
healthiness of surgical hospitals of, 247.
Copenhagen, Frederick’s hospital at. See Hospital.
‘Core’ in boil: separation of, 150.
Corpuscles of blood : no adhesiveness of, in vessels
of irritated frog’s web, 521; nor in bat, 522.
tendency to adhesion in vessels of irritated
area, 522; due to suspension of vital functions
in tissues, 523.
adhesiveness of, brought about by operation of
noxious agents on tissues concerned, 539.
natural viscidity of, 539, 540.
kept from adhering by living tissues, 539.
Corpuscles of blood, white: live long after blood shed
from body, 280; their independent movements
outside body, 512, 513.
their passage through vessels into surrounding
tissue in inflammatory conditions, 513.
accumulation of, in vessels of inflamed frog’s web,
520; phenomenon described by W. Addison
and C, J. B. Williams independently, 520 (foot-
note).
amoeboid movements seen in donkey’s blood
after it had been two days in a glass vessel, 280
(footnote).
their power of preventing development of septic
bacteria, 280.
See also Leucocytes.
Corpuscles of pus: in pyaemia not ordinary leuco-
cytes, 541.
Corpuscles of blood, red: tendency to adhere shows
in different forms according to species of
animal, or its state of health, 520, 521.
extreme adhesiveness of, in anaemia, 521 (foof-
note).
CORROSIVE SUBLIMATE AS A SURGICAL
DRESSING, ADDRESS ON (1884), 293.
Corrosive sublimate: Koch’s demonstration of its
germicidal action, 295, 296, 343.
used by Germans in form of sublimate wood
wool, 297.
experiments as to effects on albumen, 299; and
on blood, 300, 301.
associated with albumen, intact but much milder
in its action, 303.
mixed with serum in preparation of gauze, 304.
antiseptic power of, interfered with by albumen,
310.
I in 10,000 solution shown by Koch to be trust-
worthy as antiseptic, non-irritating, and non-
poisonous, 336.
strength of solutions for washing of wounds and
irrigation during stitching, 336.
INDEX TO VOLUME II
Corrosive sublimate (continued) :
substituted for carbolic acid in washing and
irrigating wounds, 343.
its effects due not to germicidal, but to inhibi-
tory action, 343.
resistance of anthrax spores and of some spore-
less micrococci to its germicidal action, 343.
weak solutions of, destroy Streptococcus pyogenes,
streptococcus of erysipelas, and Bacillus pyo-
cyaneus, 344.
carbolic acid for some time displaced by, 351.
germicidal power of, exaggerated by Koch, 351.
for surgical purposes inferior to carbolic acid, 351.
explanation of good effects when formerly used
to moisten double cyanide gauze dressing,
363.
Corrosive sublimate gauze. See Gauze.
Corrosive sublimate lotion: author’s mistake in
recommending this for destruction of microbes
in double cyanide of mercury and zinc cor-
rected, 360, 361.
reasons for using dye, 361.
Cotton wool: filters air of contained particles, 176;
hence thought likely to be useful as antiseptic
dressing if impregnated with volatile substance
capable of killing septic organisms, 176.
samples of, prepared by diffusing chlorine gas,
sulphurous acid gas, carbolic acid vapour, and
benzene vapour through, 176; all thesesuccess-
fully used as dressings, 176.
prepared by diffusion of antiseptic substance in-
effective if discharge copious enough to soak
through, 177.
sterilized by heat, objections to, as external
dressing, 345.
Cotton wool, absorbent: (preferably boiled before
use) better than water dressing in absence of
chemical antiseptics, 355.
Cotton wool, carbolated: preparation and method
of applying, 177.
Counter-irritation: by means of actual cautery,
7575
DAP as
introduced into Great Britain by Syme, 377.
Crampton, Philip: fatal secondary haemorrhage
after non-antiseptic ligature of artery with
catgut, 190.
Creosote, German. See German.
Cresswell (Merthyr Tydvil) : case of gunshot wound
of femur healed by scabbing over crust of oiled
lint covered with antiseptic putty, 76 (footnote).
compound comminated fracture of neck of femur
treated antiseptically, 193.
Crookshank, E. M.: streptococcus of erysipelas
killed by solution of sublimate, 344 (footnote).
Staphylococcus pyogenes aureus killed by carbolic
acid, 344 (footnote).
experiments on tubercle bacilli as they exist in
phthisis sputum, 352; show destructive power
of carbolic acid on, 352, 353.
history of vaccination, 505.
gives account of medical men meeting in Edin-
burgh in early part of nineteenth century to
see then unprecedented case of vaccinated
person who had taken smallpox, 505.
Crust, antiseptic, over wound: deeper parts con-
verted into living tissue, 8, 11, 94, 365.
formation of, in dressing of wounds, 75.
formed by carbolic acid and blood replaced by
living tissue, 365.
INDEX TO
Crust of clot: carbolic acid and limb in treatment
of compound fracture, 5, 6, 7.
wound closed by, in compound fracture, 30.
Cruveilhier : experimental production of suppura-
tive phlebitis of femoral vein in dog by intro-
duction of piece of wood, 132.
experiments showing how readily liquids intro-
duced into bones pass into circulation, 132
(footnote).
experiments on phlebitis, 285 (footnote).
Culture, plate of bacteria: 502; demonstrated by
Koch, 502; description of method, 503; its
importance recognized by Pasteur, 503.
Cyanide of mercury. See Mercury.
Cyanide of zinc. See Zinc.
Cyanide of zinc gauze. See Gauze.
Cysts, sebaceous, of scalp: dressing of cyanide
gauze applied after removal of, 322.
hair made into antiseptic dressing by application
of carbolic acid before removal, 371 (footnote).
Dauer-Verband (permanent dressing): Esmarch’s,
291.
Davy : lever for compression of common iliac artery
in amputation at hip joint, 415.
cases in which it has failed, 415.
Davy, Humphry: discovery of anaesthetic pro-
perties of nitrous oxide, 491.
Dead bone. See Bone.
Dead tissue: in itself unirritating, 409.
materials of which it is composed may be
absorbed, 49.
protected from putrefaction, does not of itself
disturb surrounding parts, 66.
shown by antiseptic system to be not necessarily
thrown off by suppuration, 87.
unless altered by putrefaction absorbed by sur-
rounding living parts, 87.
Decomposing substances : produce suppuration by
chemical stimulation, 40.
Decomposition: of organic substances, due to liv-
ing germs in air, 2.
illustrated by difference between pneumo-
thorax caused by puncture of lung, by fracture
of rib, and external wound penetrating chest, 3.
a self-propagating and self-aggravating poison,
41.
spreads from surface into recesses of wound
where it acquires energy of a caustic, 41.
caused by air dust, 47.
without putrefactive fermentation of discharge
in antiseptic dressing, 184, 188.
without putrefaction, example of, in stench of
discharge under vulcanized caoutchouc pro-
tective, 184; another example in stink of
serous discharge soaking into antiseptic gauze,
187.
Decomposition in fermentable substance: charac-
ter of, determined by nature of organism, 47.
Decomposition in wounds: prevention of, by ex-
clusion of air, 37.
Deformity from contracted cicatrix treated anti-
septically, 200.
Deltoid, effusion under:
256.
De Morgan, Campbell: paper on the use of chloride
of zinc in surgical operations and injuries, 52.
use of chloride of zine in dressing of operation
wounds, 131, 214 (footnote).
antiseptic opening of,
VOLUME II 567
DEMONSTRATIONS OF ANTISEPTIC SUR-
GERY BEFORE MEMBERS OF THE
BRITISH MEDICAL ASSOCIATION (1875),
2506.
Demonstrations, surgical: more
theatre than in ward, 448, 450.
De Ruyter: experiments with Behring on chemical
changes produced on toxins of bacteria by
iodoform, 356. 5
Dieffenbach’s treatment of ununited fracture, 16.
danger of amputation ‘rises by inches’, 388
(footnote).
Dietz: excision of wrist for caries, 417
Dieulafoy’s aspirator. See Aspirator.
Diphtheria bacillus : discovery of, by Loeffler, 508.
secretes toxin which poisons system, 508.
Diphtheria: toxin of bacteria in false membrane,
507, 508.
use of antitoxic serum in, 509, 510; difficulties
of problem, 510; overcome by Roux, 510;
results of antitoxic treatment, 511, 512.
complicating scarlet fever, 511; results of anti-
toxin treatment in such cases, 511.
Discharge: must always occur in certain cases,
such as contused wounds, septic sinuses,
abscesses, 338; in such cases chemical anti-
septics must be used, 339; double cyanide of
zinc and mercury most useful for purpose, 339.
Disinfectants, other than carbolic acid, may have
same effect if used on antiseptic principles, 52.
Dislocation of both shoulders: two long-standing
cases of, 324.
Dislocation, compound, of ankle:
septically,-127,/137; 141, 192:
recoveries from, formerly exceptional, 137.
appearances of wound after five weeks, 153.
Donkey : reparative energies of tissues greater than
in man, 290 (footnote).
DOUBLE CYANIDE OF MERCURY AND ZINC
AS AN ANTISEPTIC DRESSING, NOTE
ON (1907), 329.
Double cyanide of mercury. See Mercury.
Dough, carbolic acid : wound in compound fracture
closed by, 28.
Douglas’s space: adhesive inflammation of peri-
toneum a barrier to spread of bacteric develop-
ment, 285 (and footnote).
‘Drain’: use of lint steeped in carbolic acid solu-
tion as, 183, 367.
must be drawn out under antiseptic spray, 183.
Drain, catgut: used by Chiene, 444.
inferior to horsehair, 445.
Drain, horsehair: method of introduction, 443,
instructive in
treated anti-
444.
first used by White (Nottingham), 444.
used by author in chronic bursitis of sheaths of
flexor tendons at wrist, 444, 445.
its superiority to catgut, 445.
used in case of transverse fracture of patella,
446 (footnote).
method of reintroducing, 4.46.
Drain for wounds: horsehair as, 441.
Drainage tube: caoutchouc steeped in solution of
carbolic acid as means of exit for serum, 183.
advantage of, in antiseptic treatment, 216.
mode of use, 216, 217.
great importance of, in antiseptic treatment, 217.
advantages of, in treatment of wound after liga-
ture of femoral artery, 219.
568
Drainage tube (continued) :
in later stages of treatment of wound, 221.
use of, in evacuation of serous or purulent col-
lections, 221, 222, af
value of (Saxtorph), 2 24
first used by author in eed Oye
Drainage of wounds: a grand thing if could be
dispensed with altogether, 338.
‘ Dressed antiseptically’ does not merely. mean
‘dressed with an antiseptic’ but so as to en-
sure absence of putrefaction, 87 (footnote).
Dressing, antiseptic. See Antiseptic.
Dressing, external: cotton wool sterilized by heat
as, 338.
can exclude septic mischief only in dry state,
330-
to be trustworthy must be charged with some
chemical antiseptic, 345.
Dressings, carbolic. See Carbolic.
Dressing, double cyanide of mercury. See
cury.
Dressings, dry. See Dry.
Dressing, Esmarch’s. See Esmarch.
Dressings, water. See Water.
Dry dressing of wounds, 290 (footnote); has anti-
septic influence by causing inspissated state
of serum, 290 (footnote).
with cleanliness, primary union very frequent
under, 356.
Syme’s, 517,519.
Dunlop: amputation at shoulder-joint under anti-
septic system, 130.
Dunstan, Professor: composition of double cya-
nide of mercury and zinc, 329.
improvement in preparation of cyanide of mer-
cury and zinc, 339.
toma of double cyanide of mercury and zinc,
(footnote).
paces : modification of Lisfranc’s method of
amputation at shoulder-joint, 400.
Dust, atmospheric: causes development of organ-
isms and decomposition, 47.
the essential cause of organic development and
putrefactive changes in urine, 60.
filtered of germs by air passages, 61.
Tyndall’s investigations of, by means of beam
of condensed light, 175.
cotton wool filters air of, 178.
may be disregarded in operations, 342, 350.
first hint (1881) that it might be disregarded in
surgical practice, 499.
harmlessness of, demonstrated (1890), 499.
conclusion that antiseptic irrigation is not
required justified by subsequent experience,
500.
Dust of hospitals :
dant in, 344.
Dyeing of double cyanide gauze.
Mer-
pyogenic organisms not abun-
See Gauze.
Eczema: use of boracic acid in, 228.
Edinburgh: superior to London in respect of clinical
surgical teaching, 451; personal explanation
on the subject, 451, 452.
Edinburgh Royal Infirmary: no case of pyaemia
or hospital gangrene in author’s wards in nine
months (1870), 159.
two cases of erysipelas in, 159.
author’s wards free from liability to hospital
diseases, 160.
INDEX TO VOLUME II
Edinburgh Royal Infirmary (continued) :
effects of antiseptic system on salubrity of
author’s wards, 253.
one case of pyaemia (spurious) after removal of
mamma, 254.
no case of hospital gangrene in six years, 254.
erysipelas rare as a rule, but one epidemic of, 254,
number of author’s operations larger in propor-
tion to beds than Syme’s, 255.
tetanus much less frequent in, since introduction of
antiseptic system, 255.
Effusions, serous. See Serous.
Effusions, synovial. See Synovial.
Ehrlich: defensive effects of poisons derived from
vegetable kingdom, 510.
Elbow, caries of. See Caries.
Elbow, injury to: use of Réntgen rays in (Howard
Marsh), 490.
Elbow-joint, compound fracture into: |
antiseptically, 140, 155.
firmly united in five weeks, 155.
Elbow-joint : amputation of, 399.
Emphysema: caused by simple fracture of ribs, 60.
Emphysema of limb: as a complication of com-
pound fracture, 29: prevention of decom-
position in this condition, 20.
Emplastra : as vehicles for carbolic acid, objection-
able on account of adhesiveness, 71.
Emplastrum plumbi: with beeswax, as vehicle for
carbolic acid, 71.
method of preparation, 71 (footnote).
Empyema, opening of pleura in: untrustworthi-
ness of spray, 336; butresults not made worse
by false confidence in spray, 337.
Entspannungs-Ndhte (stitches of relaxation), 241.
Epidermis: special attraction of carbolic acid for,
368; experiment showing this, 370, 371.
Epithelial cancer. See Cancer.
Equivocal generation: and germ theory of putre-
faction, 57.
See also Spontaneous.
Erichsen, J. E.: author house-surgeon under, 515.
amputation of arm for hospital gangrene, 516, 517.
Erysipelas: no case in author’s wards in Glasgow
Royal Infirmary, after adoption of antiseptic
treatment, 45.
in ‘New Surgical Hospital’ in Glasgow Royal
Infirmary, 123.
only one case originating in author’s wards in
antiseptic period, 133; recurrent attacks of, in
this case seemed to show connecting link
between traumatic and idiopathic disease, 133
(footnote),
may occur in wounds from which all fermenta-
tive agency has been excluded, 241 (footnote).
epidemic of, in Edinburgh, along with outbreak
of smallpox, 241 ( (footnote), 2156s
former prevalence of, in Munich General Hospital,
248; very rare and mild since introduction of
antiseptic system in, 248, 500.
extremely rare in Volkmann’s clinique at Halle,
since introduction of antiseptic system, 250.
rare and mild in Berlin Charité Hospital since
introduction of antiseptic system, 252.
of a mild character in Magdeburg Surgical
Hospital since introduction of antiseptic
system, 252.
disappearance of, after introduction of antiseptic
system, 341.
treated
INDEX TO VOLUME II
Erysipelas of infective character: matter
necessarily offensive, 501.
Erysipelas affecting punctures of revaccination
during smallpox epidemic at Edinburgh, 241,
26K.
Erysipelas, superficial: two cases of, in author’s
wards in Edinburgh Royal Infirmary (1870),
159.
attributed to cold rather than to poisonous
atmosphere, 159, 160.
case of, in Glasgow Royal Infirmary due to chill,
in person constitutionally disposed to the
disease, 141, 159.
Esmarch: his bloodless method in operations, 213,
394-
india-rubber tube used to cause bloodlessness in
operations, 213 (footnote).
his permanent dressing, results of, 291 ; surgically
clean because aseptic, 291.
his elastic compression in amputation of thigh,
415.
Ether, sulphuric: Morton’s demonstration of
anaesthetic property of, 491.
first operation in England under, witnessed by
author, 491.
Eucalyptus gauze. See Gauze.
Excision of hip-joint, 208.
EXCISION OF. KNEE-JOINT (CLINICAL LEC-
TURE ON A CASE OF), AND HORSE-
HAIR AS A DRAIN FOR WOUNDS, WITH
REMARKS ON THE TEACHING OF
CLINICAL SURGERY (1878), 441.
EXCISION OF WRIST FOR CARIES, ON (1865),
ALT:
Excision of wrist for caries first practised by the
younger Moreau, 417; later by Dietz, Hey-
felder, and others, 417.
author’s first case, 417.
new method of operating, 418.
cases in which it was adopted, 419, 420, 421, 422,
423, 424, 425.
pyaemia after, 439, 440.
Excisions: use of chloride of zinc to sinuses in,
131 (footnote).
successful results obtained by means of anti-
septic dressing and drainage tubes, 248.
Iexfoliation: not necessarily caused by dead bone, 16.
-xtravasated blood: causing suppuration without
external wound, 21.
Extremity, lower: amputations in, 402.
Extremity, upper: amputations in, 397.
Exudation in intense inflammation special
coagulability of, 538 (and footnote), 539.
Fabricius ab Aquapendente (1618): repeats Galen’s
teaching as to amputation, 380.
Fabricius Hildanus (1633): describes ligature but
prefers red-hot knife for amputation, 380.
lehleisen: erysipelas caused by a streptococcus,
5OI, 502.
Femur : amputation through condyles of, Carden’s
method, 409, 410, 411; author’s modification
of, 410.
downward growth of, in cases of bent knee, 442.
dissection of upper part out of socket in case of
amputation of sarcoma, 413.
badly united fracture of, treated by wiring, 456.
Femur: gunshot wound of, treated antiseptically
76 (Cresswell, in footnote).
LISTER
not |
569
Femur, fracture of. See Fracture.
Fergus: case of ligature of external iliac artery
on antiseptic system, 88.
Fermentation, butyric, 47.
Fermentation: Pasteur’s work on, 492, 493, 494;
495, 497.
caused by growth of micro-organisms, 494.
Fermentation and putrefaction, causation of, 477.
Fermentation of sugar and putrefaction: parallel
between, 480.
Fermentation, vinous: caused by yeast plant, 47.
similarity of process to putrefaction, 482.
Fermentative changes caused by growth of micro-
organisms, 340.
Ferments : have each a special microbe, sor.
Ferments, self-propagating: action of, in putre-
faction, 49.
Ferments, septic: in water, 225, 226,
nature of, 226.
experiments showing that in water they are
suspended particles not equally diffused in the
liquid, 226, 227.
Fever, irritative: from suppuration; no risk of,
when abscess opened antiseptically, 34, 42.
from large abscesses, prevented by antiseptic
treatment, 48.
Fibre, absorbent: preparation of, with sublimate
serum, 307.
Fibrine: in solution, not contained in normal liquor
sanguinis, 538.
corpuscular elements of blood concerned in sup-
plying materials for formation of, 538 (foof-
note).
Fibrinogen in normal liquor sanguinis, 538.
Fibula, tumour of upper end of: operated on
antiseptically (v. Langenbeck), 252.
Finger : removal of, 397, 398.
Fissiparous generation, 483.
Fistula: prevented by antiseptic treatment of
abscess near rectum, 216.
Flap operation. See Amputation.
Flushing gouge. See Gouge.
Foot, caries of bones of: operation for, 213.
antiseptic treatment of, 214, 215.
illustrative cases, 215. See also Caries.
Forceps, dressing: author’s modification of, 222.
Forceps, sinus: description and uses of, 222.
Forearm: disabled by fracture of ulna, united at
obtuse angle, with abnormal position of radius,
165; treated by division of ulna and removal
of head of radius with antiseptic precautions,
166.
successful issue of case, 171.
Forearm: amputation in, 399.
Forearm, fracture of. See Fracture.
Fort mit dem Spray (Bruns), 280.
Fowl cholera, 504.
immunity to, produced by its attenuated virus,
504; analogy between this and vaccination
against small-pox, 504.
Fracture at ankle, old: with fixed displacement of
foot rectified by aid of antiseptic system,
72.
Fracture of femur, ununited: antiseptic operation
for, 192; details of case, 192, 193.
absorption of chips of bone produced by
roughening edge of fragments, 193.
treated by incision and removal of overlapping
fragments, 266, 2067.
Pp
570 INDEX .TO
Fracture of humerus, ununited: close stitching
avoided in antiseptic operation, 290.
illustrative case, 290.
FRACTURE OF THE PATELLA, AN ADDRESS
ON THE TREATMENT OF (1883), 453.
Fracture of patella: badly united, successful
antiseptic operation for, 349.
treatment of, 453.
long-standing: treatment of, 471.
treated by wiring, 456, 457, 458, 459, 460, 461,
462, 463, 464; method of operating, 465,
466.
Fracture of ulna: united at obtuse angle, 165;
treated by exposure and division under anti-
sepsis, 166; success of treatment, 171.
Fracture, compound: new method of treating, 1.
grave results caused by decomposition of
effused blood induced through access of air, I.
prevention of bad consequences by scabbing on
wound (J. Hunter), 2.
treatment of wound by killing septic germs, 3.
treated with carbolic acid, 28, 37, 48, 365.
antiseptic treatment of, 48, 49, 341.
antiseptic after-treatment of, 49.
wound should not be explored though slight
discharge occur if there be no inflammatory or
febrile disturbance, 49.
healing by scabbing to be aimed at, 74.
treatment of wound with undiluted carbolic
acid, 83; with watery solution of carbolic acid,
83, 84.
deeper parts of crust over wound, converted into
living tissue, 8, II, 94.
pyaemia very common in cases of, before intro-
duction of antiseptic system, 126.
amputation the rule before introduction of anti-
septic system except in mild cases, 126; since
introduction, amputation not practised except
when gangrene inevitable, 126.
antiseptic treatment of, must be thorough to be
effectual, 127.
block tin superseded in antiseptic treatment of,
142.
successfully treated under antiseptic system
(Saxtorph), 157.
antiseptic treatment of, in war, 164.
antiseptic treatment first applied to, 340.
carbolic acid successfully used for purpose, 341.
use of iodoform in treatment of, 357.
undiluted carbolic acid first applied to, in 1865,
365.
seen several hours after accident: use of 1 part
of carbolic acid in 5 of spirits of wine, 206
(footnote).
its danger as compared with simple fracture, 495 ;
this due to risk of putrefaction of wound, 495 ;
case of death from this cause in two days,
495.
Fracture, compound, of ankle: details of antiseptic
treatment, 142, 145, 146, 155.
firm union obtained in six weeks, 155.
Fracture, compound, of elbow-joint: treated anti-
septically, 140, 155.
firmly united in five weeks, 155.
Fracture, compound, of femur: treated by carbolic
acid, 18, 25.
death from haemorrhage, 24.
treated with carbolized lead plaster and healing
by granulation instead of scabbing, 77.
VOLUME II
Fracture, compound, of forearm: with simple
fracture of humerus, 9; of both bones of fore-
arm treated with carbolic acid, 24.
treated antiseptically, occurrence of putre-
faction in, I5I.
Fracture, compound, of humerus: treated by car-
bolic acid, 6, 41.
treated with carbolized lead plaster and healing
by granulation instead of scabbing, 77.
Fracture, compound, of leg: unsuccessful first
attempt at antiseptic treatment of (1865), 3.
case of successful treatment by carbolic acid
dressing, 4.
unsuccessful case of treatment by same method,5.
treated by carbolic acid, 7, 12, 28, 38.
absorption of dead bone by new tissue in, 16.
(of both legs) treated with pure carbolic acid, 29.
(of both bones of leg) treated with carbolic acid
paste, 39; treated antiseptically, 68.
author’s early experience of, unsatisfactory, 50.
unvarying success in, since introduction of anti-
septic treatment, 50.
treated with block tin and antiseptic lac, 8.
Fracture, compound, of metatarsal bone, 27.
Fracture, compound, of olecranon: treated anti-
septically, 140, 151, 155.
firmly united after five weeks, 155.
Fracture, compound, of os frontis: treated with
chloride of zinc, 52.
Fracture, compound, of tibia: treated with car-
bolic acid, 17.
treated with pure carbolic acid, 27.
Fracture, compound, of ulna: case of, treated by
carbolic acid, 6, 9.
treated with carbolic acid diluted with oil, 27.
Fracture, simple: process of healing in, 143.
antiseptic treatment of, superficial injuries com-
plicating, 232.
Fracture, simple, of ribs : causing emphysema and
pneumothorax, 60; no decomposition of blood
in, 60.
Fracture, ununited: Bickersteth’s method of
treatment by drilling, 11.
Dieffenbach’s treatment of, 16.
Fracture, ununited, of olecranon, treated by wiring,
453, 454, 455- ; ; .
Fractures, compound: treated with carbolic acid
follow same course as simple fractures, 497.
FRACTURES OF THE PATELLA OF LONG-
STANDING: REMARKS ON THE TREAT-
MENT OF (1883), 471.
Fraser: antitoxin against snake venom, 510.
Freund (Vienna): indifferent liquid behaves nega-
tively in regard to coagulation of blood, 537
(footnote).
Frontal bone, fracture of. See Fracture, os frontis.
Fungi: in bent neck of flasks containing urine, 59.
shrinking of, owing to deprivation of oxygen on
sealing neck of tube, 59.
Fungi: self-multiplication of, 483.
Gahn (Upsala): his discovery of virtues of boracic
acid, 2277
Galen: his teaching on amputation, 379.
advised cutting through dead tissues and applica-
tion of cautery to residue of mortified part,
379, 380.
Gamgee, John (New Veterinary College, Edinburgh):
method of dry dressing of wounds, 290(footnote).
7
]
q
INDEX TO
Gangrene, hospital: in compound fracture of leg,
treated with carbolic acid, 5.
mild form in compound fracture of leg, 14.
treated by nitric acid, 17.
frequency of, in Glasgow Royal Infirmary before
introduction of antiseptic treatment, 45.
in ‘New Surgical Hospital’ (Glasgow Royal
Infirmary), 123; formerly committed fearful
ravages among author’s patients, 133; ex-
amples of its destructiveness, 133; practically
banished by antiseptic system, 133, 341.
no case of, in author’s wards in Edinburgh Royal
Infirmary (1870) 150.
prevalence of, in Munich General Hospital, 248 ;
banished by antiseptic treatment, 248, 500.
practically banished from surgical hospital at
Leipzig since introduction of antiseptic system,
249.
entirely unknown in Volkmann’s clinique at
Halle since introduction of antiseptic system,
250.
very uncommon in Berlin Charité Hospital since
introduction of antiseptic system, 252.
disappearance of, in Magdeburg Surgical Hospital
since introduction of antiseptic system, 252
(and footnote).
causing recurrence of disease after excision of
wrist for caries, 435, 436, 437, 438.
not necessarily attended by unpleasant odour,
501.
epidemic of, during author’s house-surgeoncy at
University College Hospital, 516; treatment
carried out, 516, 517; his idea at that time
that disease might be of parasitic nature,
pee
Gangrene, senile: prospect of treatment of, being
revolutionized by antiseptic system, 195; this
due to prevention of putrefaction in stump,
195.
case of antiseptic operation for, 195.
Garengeot (1750): brought amputation of leg to
form often practised at present day, 384.
Gauze dressing, antiseptic: prepared by steeping
muslin in carbolic acid, paraffin, and resin,
melted together, 169 (and footnote); prepara-
tion of, 179, 202 (footnote), 210, 218, 260.
mode of use, 179, 261.
use of as dressing, 203, 207.
use of, in case of amputation at hip-joint, 204,
205.
possible source of danger at time of application,
209.
. how this may be counteracted, 209.
times of changing, 210.
cheap method of preparation, 210, 211,
lowest piece dipped in watery solution of car-
bolic acid to kill septic particles adhering to
surface, 260.
mode of applying, 261.
importance of thick mass of, in limited space,
266.
no organism found in, if changed daily, 294.
Gauze, carbolic : soaked with serum and inoculated
with putrid blood remains pure, 305.
disadvantages as external dressing, 358.
Gauze, corrosive sublimate: preparation of, 297.
used oe a case of removal of cancerous breast,
297, 29
action a on albumen of serum or blood, 290.
212.
VOLUME II
971
Gauze, corrosive sublimate (continued) :
as dressing in case of psoas abscess, 303, 304.
made by serum mixed with corrosive sublimate,
304.
absolutely non-irritating, 305.
should be cut with scissors,
(footnote).
Gauze, cyanide of zinc and mercury :
of, 327, 360, 361.
staining of, with haematoxylin, 327, 3
importance of its being used moist, 32
mode of charging with dye, 330.
Gauze, double cyanide of mercury :
in preparation of, 317, 318.
its advantages, 319.
method of application, 31¢.
wounds heal better than
dressing, 319.
haematoxylin as dye for, 361.
hydrochlorate of mauveine (purified rosalane)
better, 361, 362.
method of dyeing, 362.
method of charging, for emergency in private
practice, 362, 363; mode of avoiding staining
hands in, 362 (footnote).
cost of, 362.
Gauze, double cyanide ot mercury and zinc :
be wetted with
360.
author’s mistake in recommending corrosive
sublimate lotion for destruction of microbes
in, corrected, 360.
reasons for using dye, 361.
Gauze, eucalyptus: as an external dressing, 294.
imperfections in its manufacture, 294.
used as external dressing over corrosive sub-
limate, 297.
soaked with serum and inoculated with putrid
blood remains pure, 305.
Gauze, sal-alembroth: disadvantages of, as a dress-
ing, 312.
Gauze, sero-sublimate :
corpuscles, 306.
use of, as dressing, 306.
causes no irritation, 306.
successfully used in case of amputation at hip-
joint, 306, 307; and in case of removal of
portion of rib for empyema, 307.
disadvantages of, 358.
abandoned by author, 358.
Gauze, zinco-cyanide of mercury:
dyeing, 325.
experiments with different staining agents, 325.
effects of violet gentian in fixing the cyanide and
preventing dusting, 326.
later experience shows that haematoxylin acts
better, 327.
Gay-Lussac: his teaching that access of free
oxygen could start fermentation in organic
substances, 340.
influence of this doctrine in treatment of wounds,
340.
Generation, equivocal: and germ of putrefaction,
57. See also Spontaneous.
Generation, fissiparous. See Fissiparous.
Germ theory: the basis of antiseptic treatment, 46,
479.
importance of attention to details dictated by,
tor successful results, 94.
not torn, 305
preparation
28.
7, 328.
experiments
under any other
must
carbolic acid before use,
stands test with serum and
advantage of
Pp2
374
Germ theory, Pasteur’s: author’s experiments in
confirmation of, 499.
Germ theory of putrefaction, 54, 172.
experiments illustrating, 54; experiment on
urine in flasks with bent necks, 55.
and equivocal generation, 57.
the guiding principle of antiseptic treatment,
L72,
the basis of antiseptic surgery, 479.
first step towards establishment of, the discovery
of yeast-plant by Cagniard-Latour in 1836,
479.
originated by Schwann, 479, 480.
experiments undertaken with view of confuting,
likely to fail, 480 (footnote).
illustrated by opening of abscess, 480, 481.
Germ theory of septic diseases established, 323.
‘German creosote’: an impure carbolic acid with
which author’s first experiments were made, 67.
or crude carbolic acid, first used for compound
fracture, 367.
Germany: antiseptic treatment in, 248.
Germicidal antiseptics: kill organisms, 296, 359.
Germs: killing of, in wound of compound fracture,
3.
all forms of life originate from, 57.
Germs in air, 483; killed by high temperature, 47.
how prevented from passing through bent necks
of flasks, 58.
in inhaled air stopped by air passages, 61.
Glanders: produces toxin (mallein), 509; this useful
for diagnostic purposes, 509.
Glasgow Royal Infirmary: influence of antiseptic
treatment on healthiness of author’s wards in,
45, 123, 500.
antiseptic system originated in, 51.
description of ‘ New Surgical Hospital ’ in, 123.
Gloucester : epidemic of smallpox at (1896), 505.
Goitre: circumferential ligature of thyroid vessels
before removal of, 102.
Gooch’s splint: for stump after amputation of
thigh or leg, 396.
use of, after excision of knee-joint, 447; after
wiring of patella, 473.
Goodsir: first opened up path pursued by Virchow
in ‘ Cellular Pathology ’, 150 (footnote).
Gouge, flushing: use of in psoas abscess, 346, 347
(footnote).
Grafting of skin. See Skin.
Graham: his researches into laws of gaseous
diffusion, 178.
Granulating surfaces: coalescence of, 147.
Granulation and suppuration, 82.
Granulations: form protective layer on raw sur-
face, 2.
process of absorption of dead bone by, 16, 66,
Li7, TAS.
may act as absorbents, 17.
no inherent tendency in, to form pus, 40, 147,
449.
production of, 49.
may be produced by antiseptics, 49.
do not secrete pus, 147.
abscess wall essentially similar to, 148.
development of, into fibrous tissue of cicatrix,
148.
excited to superficial suppuration by stimulating
action of antiseptics, 148 ; and by products of
putrefaction, 148. ~
INDEX TO VOLUME II
Granulations (continued) :
precede suppuration, and process requires days
for its completion, 150; exception to this rule
in case of epithelium of some mucous mem-
branes which forms round pus corpuscles under
slight stimulation, 150 (footnote).
constitute protective layer destitute of sensibility,
448.
unite with freshly cut surface, 449.
in open wound, structure of, 496.
Granuligera: in hempen ligatures applied to thy-
roid vessels, 103.
one species very frequent in wounds treated anti-
septically, without interference with aseptic
progress, 103.
‘Guard ’, antiseptic: use of, 181.
Guérin, Alphonse: his method of dry dressing in
wound, 290 (footnote).
Gullet : halfpenny in, shown by Roéntgen rays, 490.
Gunshot wounds: antiseptic treatment of, 161.
should not be stitched, 161 (footnote).
Haematoxylin: as a dye for cyanide of zinc and
mercury gauze, 325, 327, 361.
its effect in fixing the cyanide, 327.
as dye in double cyanide gauze.
Haemorrhage : in compound fracture, fatal case of,
24.
arrest of, 25.
Haemorrhage: after ligature of artery, more
frequent from distal than from cardiac end, 86
(footnote); explanation of this, 86 (footnote).
Paré’s advocacy of ligature for, 379.
Celsus on arrest of, 379 (footnote).
Haemorrhage, venous: use of catgut ligature for
arrest of, 271.
Hagedorn : effects of antiseptic treatment in Sur-
gical Hospital at Magdeburg, 252 (footnote).
Hair, human: its attraction for carbolic acid, 370
(and footnote); hence it may be turned to
account as antiseptic dressing, 371.
case of removal of sebaceous cyst from scalps in
which this was done, 371 (footnote).
Halle: antiseptic treatment at, 249.
Harelip: use of button suture after operation for,
2425243.
use of silver wire for deeper stitches and horse-
hair for superficial ones, 245.
‘ Hat-lining’ as an antiseptic dressing, 1709.
use of, in antiseptic gauze dressings, 207.
Haycraft: castor oil behaves negatively in regard
to coagulation of blood, 537 (footnote).
Healing: more rapid in proportion to efficiency
of ‘ protective’, 154.
without suppuration in dry dressing, 290 (foot-
note).
of wounds by organization of blood-clot without
suppuration under antiseptic treatment, 291.
HEALING ART, THE: INTERDEPENDENCE
OF SCIENCE AND (1896), 489.
Healing by ‘first intention ’, formerly exceptional,
496.
Healing by granulation and cicatrization, 496.
Healing of sore. See Sore.
Healing of ulcer. See Ulcer. ‘
Heart : shown in living body by means of Rontgen
rays, 491.
Hectic: from suppuration; no risk of, when
abscess is opened antiseptically, 34, 42.
INDEX TO
Hectic (continued) :
from large abscess, prevented by antiseptic
treatment, 48.
Hemmung: word used by Germans to describe
checking action of certain antiseptics without
destruction of volatile salts, 296.
Hempen ligatures, antisepticized: applied to
thyroid vessels before removal of goitre, 103;
come away unaltered, but loaded with micro-
cocci, 103.
Hernia, irreducible : Syme’s treatment for, 191.
antiseptic operation for, 191.
Hernia, strangulated inguinal : antiseptic operation
im, 44.
Hernia, umbilical, irreducible :
tion for, 191.
Hernia, ventral: cleansing of skin with carbolic
acid in operation for, 369.
Hernia, ventral, irreducible: antiseptic operation
for, I9I.
Hey (Leeds): method of amputation by ‘triple
incision ’, 383.
‘circular operation ’, perfected by, 383.
method of separating metatarsus from tarsus,
403, 404.
Heyfelder : excision of wrist for caries, 417.
Hill, Berkeley: witnesses first dressing in case
of compound dislocation of ankle treated
antiseptically, 141.
Hip, caries of. See Caries.
Hip-joint: amputation at, 412, 413, 414, 415, 416.
antiseptic dressing in, 199,
primary amputation at, recovery, 203.
details of antiseptic dressing, 204.
amputation of, for sarcoma, dressed with sero-
_ sublimate gauze, 307.
Hip-joint disease: abscess connected with, failure
of antiseptic dressing necessitating excision,
207, 208.
with putrid sinuses, rapid healing after anti-
_ septic excision of, 251.
Hip-joint, necrosis of: treated antiseptically with-
_ Out suppuration, 66,
Hippocrates: his teaching on amputation, 378;
care to be taken not to wound any living
parts, 378.
History of antiseptic surgery: some points in, 365;
author’s aim to avoid direct action of antiseptic
substance on tissues, 365; antiseptic principle
first applied to compound fractures in 186s,
365; use of undiluted carbolic acid in com-
pound fractures, 365; formation of crust of
blood and carbolic acid, 365 ; tissue destroyed
by the caustic replaced by living tissue, 365 ;
this a new truth in pathology which afterwards
suggested idea of catgut ligature, 365 ; applica-
tion of antiseptic principle to abscess, 366;
abscess after opening dressed with carbolic
putty, 366; strips of lint left in as drain, 366;
drainage tube devised, 367; solubility of car-
bolic acid crystals in water, 367; use of watery
solution as antiseptic in treatment of wounds,
367; watery solution of carbolic acid, carbolized
oil, and carbolic putty, various uses of, 368;
purification of skin and instruments, 369; de-
tergent properties of carbolic acid, 369, 370;
fear of poisonous effects from carbolic gauze
as used in antiseptic surgery groundless, 370
(footnote); needless substitution of complicated
antiseptic opera-
VOLUME II 573
History of antiseptic surgery (continued) :
measures for use of carbolic acid, 370; pre-
liminary washing with soap and water not
only useless if carbolic acid is used, but
injurious, 370; greater attraction of carbolic
acid for epidermis than for water shown by
experiment, 370.
Holmer (Copenhagen): antiseptic treatment after
division of cicatricial web of axilla, 201.
Horse: antiseptic ligature of carotid artery in, 64
post-mortem examination of parts, 64.
results of experiments justifying application of
method in man, 65.
Horsehair: structure of, 245.
as a drain for wounds, 414. See also Drain.
Horsehair stitches: in operation for harelip, 245.
Hospital construction: importance of antiseptic
treatment in relation to, 135.
Hospital diseases : freedom from, due to antiseptic
treatment, 160.
Hospital, Fever : close to ‘ New Surgical Hospital ’
(Glasgow Royal Infirmary), 126.
Hospital, Frederick’s, Copenhagen: Saxtorph’s
experience of beneficial effect of antiseptic
system in healthiness of, 156.
no case of pyaemia since introduction of system,
1506.
Hospital Gangrene. See Gangrene.
Hospital, Surgical: effects of antiseptic system of
treatment on salubrity of, 123, 156, 247.
‘Hospital, Surgical, New’ (Glasgow Royal Infir-
mary): unhealthiness of, 123 ; ground floor of, the
most unhealthy, 124; emanations from foul dis-
charges and from open sores the great source of
unhealthiness in, 124; author’s resistance to
introduction of additional beds in his wards,
124; excessive mortality in another ward leads
to investigation and discovery underneath of
coffins with corpses, placed there in cholera
epidemic of 1849, 124; yet no pyaemia, erysi-
pelas, or hospital gangrene in author’s wards
during nine months previous to this discovery,
on account of antiseptic system of treatment,
124; how the corrupting mass underneath was
dealt with, 125; bad situation of, 125.
Hospitalism: banished by antiseptic treatment
(Saxtorph), 247.
Hospitals: antiseptic treatment and healthiness
of, 45, 341. :
malignant influence of impure atmosphere of,
removed by antiseptic system, 136
Saxtorph’s testimony as to beneficial effects of
antiseptic system on atmosphere of, 197 ; simi-
lar testimony of Bernard in regard to Naval
Hospital at Plymouth, 197. :
no longer pest houses after introduction of anti-
septic system, 341.
pyogenic organisms not abundant in dust of, 344.
Humphry, G. M.: amputation of penis, 235 (foofnote).
Hunter, John: prevalence of bad consequences ot
compound fracture by formation of scab on
wound, 2.
‘stimulus of necessity ’, 241.
HUXLEY LECTURE, THE THIRD (1900), 515.
Hydrocele fluid: coagulation of, by addition of
serum from blood-clot, 257.
Hydrocele, serum of: is normal plasma, 539.
Hydrochlorate of mauveine. See Rosalane.
Hydrophobia: Pasteur’s researches on, 506.
574
Hydrophobia (continued):
virus has its seat in nervous system, 506.
artificial production of, in rabbits, 506.
inoculation, methods of diagnosis, 506.
reinforcements of virus, 507.
immunization against, 507.
Hypospadias: operation for, 236.
boracic lint as dressing after, 237.
Iliac artery. See Artery.
Immunization: against fowl cholera, 504.
against smallpox, 504.
against anthrax, 504.
against hydrophobia, 507.
India-rubber: easily impregnated with carbolic
acid, but parts with it rapidly, 77 (footnote).
India-rubber rod: traction with, after division of
cicatricial web, 202.
Infective disorders: all microbic in origin, 502.
Infirmary, Edinburgh Royal. See Edinburgh.
Infirmary, Glasgow Royal. See Glasgow.
Inflammation: kept up by presence of fluid in
sac of bursa patellae, 223; emigration of leuco-
cytes in, 333, 334; in wounds due to decom-
position of blood, 496; author’s early lectures
on, at Edinburgh, 518; tendency of blood cor-
puscles to adhesion in, 521, 522, 523.
Inflammation, acute or chronic: must degrade
tissues before it causes formation of pus, 150 ;
this illustrated by process in a boil, 150.
Inflammation, direct: caused by operation of
noxious agents on tissues, distinguished from
indirect produced through nervous system, 5 33
illustrated by lymph between cut surfaces, 533,
534-
both forms commonly more or less associated,
534-
Inflammation, indirect : produced through nervous
system, 533.
Inflammation, intense : may be produced by opera-
tion of a noxious agent on tissues, or indirectly
through nervous system, 147.
Inflammation, mere : does not induce putrefaction,
481.
Inflammatory congestion : vital energies of affected
tissues prostrated in, 527.
a cause of abnormal effusion of liquor sanguinis
from vessels, 533.
Inflammatory stasis: Wharton Jones’s researches
on, 518.
author’s experiments on, 518, 519, 520.
Influenza bacillus: discovered by Pfeiffer, 502.
Inguinal hernia. See Hernia.
‘Inhibitory’ antiseptics: check development but
do not destroy vitality of organisms, 296.
Inhibitory power in antiseptics, 359.
Innominate artery. See Artery.
Instruments: necessity of keeping them antiseptic
during operations, 219.
Instruments with teeth:
required, 354, 355.
Intramural interment: proposed abolition of, in
Glasgow, 126 (footnote).
Iodide of mercury. See Mercury.
lodoform: prevents putrefaction, but is not a
powerful germicide, 295.
experiments with, on milk and urine, 295.
has little influence on growth of bacteria outside
body, 356; experiment showing this, 356.
special purification
INDEX TO VOLUME TI
Iodoform (continued) :
has powerful antiseptic influence on wounds, 356.
said by Behring not to act directly upon bacteria,
but to produce changes in their chemical
products, 356.
some bacteria more affected by, than others, 356
(footnote).
a poison to cholera microbe, 356 (footnote).
useful for dusting cut surfaces, 357.
of very high antiseptic value in operations on
mouth or rectum, and in treatment of putrid
sinuses, 357.
probably best dressing on battlefield, 357.
useful in compound fractures, 357.
not recommended in operations where integu-
ment is unbroken, 357.
virtues especially displayed in interior of wound,
357-
Iodoform dressing: no security against penetra-
tion of septic microbes to outlet of wound, 357.
lodoform wool: soaked with serum and inoculated
with putrid blood stinks after a few weeks, 305.
Irrigation, antiseptic, of wounds: can be dis-
pensed with, 351.
Irritant: producing inflammatory congestion, causes
suspension of vital tissues on which it acts,
527.
Irritative fever. See Fever.
Jackson, Herbert: demonstration of bones, «c.,
by means of Rontgen rays, 491.
Jenner, Edward: his view that vaccination is
small-pox in the cow adopted by Pasteur, 504.
his crucial experiment of inoculating with small-
pox a boy previously vaccinated, 504; this a
legitimate experiment, 504.
centenary of his discovery evoked no general
recognition in this country, 505.
Joint, caries of, with sinuses: partial excision of,
unsatisfactory, 194; may sometimes be done
successfully by antiseptic method, 195 ; illustra-
tive cases, 195.
Joint disease: advantages of actual cautery in,
37 3-
Joints: can be freely opened in antiseptic atmo-
sphere followed up with antiseptic dressing,
194; illustrative cases, 194.
free incision of, under spray, prevents suppura-
ration and avoids amputation or excision, 194.
antiseptic treatment of wounds of, 257.
Joints, caries of. See Caries.
Jones, Wharton : his Astley Cooper prize essay on
arrest of red corpuscles in capillaries of inflamed
part, 518.
Jordan, Furneaux: operation for phimosis, 234.
verifies absence of pulsation in external iliac
artery at groin after ligature, 269.
amputation at knee-joint, 413, 414.
Keith, Thomas: successful ovariotomies in pre-
anaesthetic period, 275.
author at first dissuaded him from operating
antiseptically, 275.
series of eight successful ovariotomies
improved antiseptic spray, 276.
spray afterwards abandoned by, 276.
his scrupulous attention to cleanliness, 276 (foot-
note).
his use of boiled sponges, 276 (footnote).
with
INDEX TO
Keith, Thomas (continued):
withdrawal of putrid liquid from Douglas’s space,
285.
Kelvin, Lord: celebration of his jubilee at Glasgow,
504, 505. ;
Kidneys: inflammatory congestion of, following
lithotomy, 532; caused by urethral irritation,
532 sS3- ae.
Kitasato: discovery of antitoxic serum, 509.
Knee: amputation through, 410.
Knee, caries of. See Caries.
Knee-joint: extraction of fragment of tibia from,
under antiseptic treatment (Saxtorph), 157.
removal of loose cartilage from, under antiseptic
spray, 194.
effusion into, antiseptic opening of, 256, 257, 258,
259, 260, 261.
case of antiseptic incision into, 259, 260, 261.
tension from further effusion relieved by in-
sertion of longer drainage tube, 262, 263.
details of operation and dressing, 263.
removal of loose cartilage from, with and without
antiseptic precautions, 289.
amputation at (Pollock in footnote), 411.
Knee-joint, excision of: clinical lecture on, 441.
shortening of limb after, 441.
details of operation, 443.
demonstration of cases, 441, 442, 446, 447, 448,
449.
Koch, Robert : demonstration of germicidal action
of corrosive sublimate, 295, 296.
researches on antiseptic properties of bichloride
of mercury, 310.
demonstration of method of cultivating microbes
as solid media, 332.
discovery of cholera microbe, 332, 503
teaches that I in 10,000 solution of corrosive
sublimate is trustworthy as antiseptic, and at
same time unirritating and non-poisonous,
336 343-0 ; |
antiseptic properties of corrosive sublimate, 343.
discovery of tubercle bacillus, 347.
exaggerated germicidal power of corrosive sub-
limate, 351.
researches in infective diseases of wounds in
lower animals, 502.
discovery of tubercle bacillus, 502.
‘plate culture’ of bacteria, 502, 503; importance
of method recognized by Pasteur, 503; tuber-
culin and its effects, 508; disappointment
caused by premature publication, 508 ; but his
work inspired Behring and Kitasato in dis-
covery of antitoxic serum, 509.
Kolliker : his discovery of fibre cells of involuntary
muscle, 520.
Lac: tried as material for antiseptic cement, 77.
its advantages over lead plaster, 77.
holds carbolic acid very tenaciously, 77.
its disadvantages and how they are obviated,
Lac, antiseptic, with block tin: in treatment of
contused wound, 79.
in treatment of compound fracture (leg), 80.
Lac, carbolized: impermeable to discharge, 83.
combines properties of external antiseptic guard
with those of permanent crust, 83.
advantages of, as a dressing combined with
block-tin, 83.
VOLUME II
575
Lac plaster: as a vehicle for carbolic acid, 71
(footnote).
retains carbolic acid with great tenacity, 77.
improved by incorporation with soft cloth
instead of being spread on starched calico,
139.
Lac plaster, carbolized: spread upon gutta percha
tissue as antiseptic cement, 77.
greatly superior to lead plaster, 77.
cracks at fold of joint, 77; how this disadvan-
tage is obviated, 77.
mode of manufacture, 78 (footnole).
how made non-adhesive, 77.
how made adhesive, 78.
combined with block-tin or sheet-lead to protect
exposed tissues from stimulating antiseptic, 78.
replaced by folded muslin cloth imbued with
mixture of paraffin, resin, and absorbing cloth
167.
See also Plaster.
Langenbeck, v.: his first antiseptic operation, 252.
flat elastic bandage for upper limb, 396.
Larrey: results of amputation at shoulder-joint in
military practice, 400.
his method of operating, 401, 402 (footnote).
Laughing gas. See Nitrous Oxide.
Laulanier, Professor (Toulouse): stained sections
of vessels and adherent coagulum prepared by,
284 (footnoie).
Lawrence, W.: fine silk ligatures left with short
cut ends in a stump may appear after healing
of wound, 92.
Lead plaster: as vehicle for carbolic acid, 71.
carbolized, useful as external antiseptic guard
in compound fracture, incised wounds, and
abscesses, 76.
unsuitable for permanent dressing, 76.
Leather ligatures, unasepticized: tried and found
unsatisfactory, 92.
Leg, amputation of. See Amputation.
Leg, compound fracture of. See Fracture.
Leg, death two days after compound fracture of,
from putrefaction of wound, 495.
Leipzig: antiseptic treatment at, 240.
pyaemia and hospital gangrene almost entirely
banished, 249.
Leucocytes, phagocytic: action of, 333.
emigration of, in inflammation, 333, 334, 542.
soon penetrate very thin spaces between
chemically inert foreign bodies inserted among
tissues, 334; hence may creep into silk thread
and destroy microbes lodged there, 335.
phagocytic power of, 542.
Liebig: loss of property of causing crystallization
by heated glasses, 300.
fermentation produced by access of oxygen to
organic substances, 340.
germ theory of putrefaction discredited by, 493.
his teaching that primary cause of putrefaction
is atmospheric oxygen, 497.
Ligature, antiseptic. See Antiseptic.
LIGATURE OF ARTERIES ON THE ANTI-
SEPTIC SYSTEM, OBSERVATIONS ON
(1869), 86.
Ligature of arteries. See Arteries.
Ligature: use of, recommended by Celsus for arrest
of haemorrhage after amputation, 379 (and
footnote),
Ligature : method of tying in amputation, 393, 394.
576
Ligature, aseptic: does not cause irritation, but
strengthens vessel by replacement of catgut
by ring of living tissue about the vessels, 190.
Ligature: for arrest of haemorrhage: Paré’s
strenuous advocacy of, 379 (footnote).
slowness of surgeons in sixteenth and seventeent
centuries to adopt it, 379. :
Ligature made of peritoneum. See Peritoneum.
Ligature, septic: effect of, on arteries, 86.
a cause of secondary haemorrhage, 86 (and foot-
note on same page).
death caused by diffuse suppuration after, 87.
irritation of, causes softening of external coat
and haemorrhage, 190.
Ligatures may be cut short and left under anti-
septic treatment, 44.
Ligatures, animal. See Animal.
Ligatures, catgut. See Catgut.
Ligatures, hempen. See Hempen.
Ligatures, leather. See Leather.
Ligatures, silk. See Silk.
Ligatures, tendon. See Tendon.
Limb, upper: more favourably circumstanced for
amputation than the lower, 396.
Lindpaintner: sent by v. Nussbaum to Edinburgh
to learn antiseptic system, 500.
Linen, old (preferably boiled before use): better
than water dressing in absence of chemical
antiseptics, 355.
Lint, boracic. See Boracic.
Lip, lower: boracic ointment dressing after plastic
operations for repair of, 244, 245.
Liquor chlori, B.P.: application of, to wound in
which putrefaction had occurred, 155.
Liquor sanguinis: abnormal effusion of, in acute
inflammatory disturbance, 533; causing
‘brawny’ swelling of parts, 533; how this
differs from ‘ doughy’ character of oedema, 5 33.
Lisfranc : method of amputation at shoulder-joint,
400; Dupuytren’s modification of, 400 (footnote).
method of separating metatarsus from tarsus,
403.
LISTER, THE LATE JOSEPH JACKSON,
OBITUARY NOTICE OF, WITH SPECIAL
REFERENCE TO HIS LABOURS IN THE
IMPROVEMENT OF THE ACHROMATIC
MICROSCOPE (1870), 543.
Lister, Joseph Jackson: improvements in micro-
scope based on principles introduced by, 502.
his improvements in compound microscope, 515.
early predilection for optics, 543.
note (1824) of first attempt to improve achro-
matic microscope, 543, 544.
camera lucida invented by, 545.
his criticism of Chevalier’s plano-convex lenses,
545.
experiments with Utzschneider and Frainho-
fer’s plano-convex lenses, 546, 547.
discovery of aplanatic foci, 547, 548.
experiments on object glasses, 549.
letter to Sir John Herschel, 5409, 550.
observations on zoophytes, 550.
unpublished paper on limits of human vision,
550.
his relation to the British microscope, 550, 551.
described as ‘the pillar and source of all the
microscopy of the age’, 551.
his wide intellectual interests and character, 552.
his death, 552.
INDEX TO VOLUME II
Liston, Robert: strongly advocated flap operation
in removal of limbs, 384, 385 ; modified circular
method, 385.
catch forceps introduced by, 393.
bone pliers introduced by, 393.
first operation performed in England under
ether, 491.
amputation of thigh under chloroform, 491,
492.
his preference for ‘ water dressing ’ over ‘ filthy
unguents ’, 517.
Lithotomy: rigor and inflammatory congestion
of kidneys following, 532.
Lockjaw. See Tetanus.
Lodge, Oliver: radiograph of bullet embedded in
hand, 491.
Loeffler : discovery of bacillus of diphtheria, 508.
Logwood. See Haematoxylin.
London: inferior to Edinburgh in respect of
clinical surgical teaching, 451.
personal explanation on the subject, 451, 452.
Louis: method of amputation of thigh, 382.
the first to employ digital compression of femoral
artery instead of tourniquet, 382.
did not aim at complete covering of bone, 383
(and footnote).
Lowdham, C. (Exeter): suggests method of am-
putation with single flap, 383.
Lucas-Championniére : wiring of fractured patella
of long standing without division of quadriceps
extensor, 471.
Lung: puncture of, without external wound, no
decomposition in, 3.
puncture of, by simple fracture of rib, no
decomposition of blood from, 60; air in pleura
may press on other lung, 60; case of death
from this cause, 60.
Lymph: vascularization of, 118
Lymph, organizing: its resistance to development
of putrefactive bacteria, 286.
Macfadyen, Allan: experiments on germicidal
properties of infusion of catgut prepared with
chromium sulphate and corrosive sublimate,
I2i, 122t
Macintosh : use of, as an antiseptic dressing, 179,
207, 208.
imperfection in, leading to putrefaction, 208.
use of, in antiseptic gauze dressings, 261.
Macintyre, John: halfpenny in boy’s gullet shown
by Rontgen rays, 490, 491.
Mackenzie, Richard: amputation at ankle, 406.
Magdeburg: effects of antiseptic treatment at,
22:
Mallein : toxic product of glanders, 509.
its use for diagnostic purposes, 509.
Mamma: removal of, for scirrhus with division of
both pectorals and clearance of axilla under
antisepsis—wound healed in three weeks, 158.
compound antiseptic dressing after removal of,
208.
use of button suture after removal of, 242.
venous haemorrhage after removal of, and clear-
ing out axilla, 271, 272, 273.
Mamma, scirrhus of: case of death from spurious
pyaemia or a variety of septicaemia after
antiseptic operation for, 293.
removal of congestion caused by stitches, illus-
trating influence of nervous system, 528.
INDEX TO VOLUME II
Marsh, Howard: use of Réntgen rays in case of
injury to elbow, 490.
Martindale, W.: calls attention of author to cya-
nide of mercury as antiseptic, 312.
suggests double cyanide of mercury and zinc as
antiseptic dressing, 313; experiments prove it
to have powerful antiseptic properties, 313.
Mason, T., and Son: formula of double cyanide of
mercury and zinc, 320.
Maxillary bones: offensive character of discharge
after removal of portions of, 53; this pre-
vented by use of chloride of zinc, 53.
Maxillary bones, cancer of. See Cancer.
Meatus urinarius, defective: operations for, 238,
239-
Medical diseases: differ from surgical not so much
in nature as in situation, 450.
Mercury, bichloride. See Corrosive sublimate.
Mercury, cyanide: author’s attention called to,
as possibly valuable antiseptic, 312.
experiments with, 312.
remarkable inhibitory power of, 312, 313.
its germicidal power low, 313.
very irritating, 313.
superior to bichloride in inhibitory power, but
inferior as germicide, 360.
Mercury, double cyanide of: and potassium tried
as antiseptic dressing and found too irritating,
313; experiments with, in preparation of anti-
septic gauze, 317, 318, 319.
efficient as inhibitor but not as germicide, 3109.
See also Mercury zinco-cyanide.
Mercury, double cyanide of, and zinc, experiments
on antiseptic power of, 313, 314.
Mercury, double cyanide of, dressing: use of rags,
old linen, old towels for, 363.
application of macintosh over,
discharge anticipated, 363.
Mercury, double cyanide of, powder: made with
carbolic lotion into soft mud or cream, used
in vicinity of anus, 363; applied to pubes con-
verts hairs of part into antiseptic dressing,
363.
Mercury, double cyanide of, and zinc : composition
of, 329, 358.
formula of, 329, 358 (Dunstan in footnote).
purified rosalane as dye for, 329.
method of charging gauze, rags, &c., with, 330.
has remarkable inhibitory power over bacteric
development, but is not efficacious as germi-
cide, 330.
useful in military practice as first dressing,
330.
G,. Lenthal Cheatle’s experiences of it made into
a paste, on battlefield in South Africa, 331
(footnote).
Dunstan on composition of, 329; improvement in
preparation of, 339; formula of, 358 (footnote),
cyanide of mercury the more important ingre-
dient antiseptically, 339.
constancy of aseptic results with, 339.
nearest approach to ideal antiseptic, 345.
inhibits development of microbes, 345, 360.
very feeble as germicide, 345, 360.
should be moistened with carbolic acid solution
before use, 345.
bichloride of mercury of little use for this pur-
pose, 346 (footnote).
most satisfactory antiseptic for dressing, 358.
when free
577
Mercury, double cyanide of, and zinc (continued) :
experiment showing its efficacy in preventing
bacteric development, 359.
gauze charged with, must first be charged with
carbolic acid, 360.
Mercury, double cyanide gauze. See Gauze.
Mercury, iodide, gauze: trial of, 314.
answers well as antiseptic, but causes great
irritation, 314.
author’s dissatisfaction with, 315.
Mercury, zinco-cyanide: experiments proving it
to possess powerful antiseptic properties, 313,
314.
preparation of dressings of, 314.
disadvantages of, 314.
given up for time being, 314.
further experiments with, 316.
little mercury in, 320.
a trustworthy antiseptic in surgical practice, 322.
composition of, uncertain, 322.
used in hairy parts converts hairs into anti-
septic dressing, 322.
successfully applied in removal of sebaceous
cysts of scalp, 322.
most satisfactory dressing yet (1889) met with
by author, 323.
as antiseptic dressing, 320.
Meredith, Dr. (I.M.S.), informs author of Tyn-
dall’s experiment on dust in air and suggests
cotton-wool as dressing, 176 (footnote).
Metacarpal bone: excision of, 398.
Metal covering: prevents suppuration in healthy
granulation wounds, 40.
Metatarsal bone: removal of, 402, 403.
Metatarsus: separation of, from tarsus, 403; Hey’s
method of operating, 403, 404; Lisfranc’s
method, 403; Astley Cooper’s method, 404.
Metchnikoff: his discovery of phagocytes, 332:
confirmed by Tchistovitch and Armand Rutffer,
332 (footnote).
experiments on action of phagocytes, 333, 334.
process of phagocytosis, 350.
absorbent power of white corpuscles, 513.
phagocytic action of cells in water-flea on spores
of invading fungus, 513.
phagocytosis as defensive means against invading
microbes, 513, 514.
phagocytic power of leucocytes, 542.
Microbe of cholera: Koch’s discovery of, 332, 503.
poisoned by iodoform, 356 (Neisser, im footnote).
Microbe, poisonous: each forms special toxin, 508.
Microbes: Koch’s method of cultivating on solid
media, 332.
entire exclusion of, from wounds impossible,
341; and unnecessary, 341.
air of every inhabited place teems with, 340.
only a small proportion of them capable of doing
mischief in surgery, 350.
importance of, in economy of Nature, 494, 495.
growth of, the cause of putrefaction, 497.
do not originate de novo, 497.
even the injurious species not sure of gaining
a footing when introduced into wounds, 250.
Microbes, ultra-microscopic, 502.
Micrococci: in acute abscesses, 347.
species of, shown by Cheyne to occur frequently
in cases treated antiseptically without inter-
ference with aseptic progress, 103.
sometimes mischievous, 103.
578
Micrococci (continued) :
case in which they caused suppuration, 104.
action of carbolic acid on, more uniform than that
of corrosive sublimate, 344.
Micrococci, sporeless: our surgical enemies, 351.
Micro-organisms: blood serum not so favourable
a soil for growth of, as once believed by author,
277
relation of, to wounds, difficulties in regard to
explained by phagocyte theory, 334.
growth of, causes putrefaction and other fer-
mentative changes, 340.
effects of, on living body greatly influenced by
numbers, 342; this explains how attenuated
and subdivided bacteria in atmosphere are
disposed of by antiseptic action of blood and
living tissues, 342.
importance of, in economy of Nature shown by
Pasteur, 494, 495.
Microscope, achromatic: J.
improvement of, 543.
Microscope, compound :
ments in, 515.
Microscopes: improvements in, based on principles
introduced by J. J. Lister, 502.
Military hospitals : antiseptic treatment necessary
even in superficial granulating sores to main-
tain healthy atmosphere, 164.
Milk, uncontaminated: addition of drops of water
to, causes bacteric development, 277.
affords pabulum for almost all varieties of micro-
organisms, 277.
Miller (in Chemistry) : his statement that albuminate
of mercury is found as precipitate when solu-
tion of albumenis treated with corrosive subli-
mate, 299.
Milne-Edwards: and Pasteur’s experiments on
germs in air, 485.
‘Minikin gut.’ See Catgut.
Moreau the younger: first excised wrist for caries,
417.
Morel: invention of tourniquet by (1674), 381.
Morton, T.: compound fracture of forearm treated
with carbolic acid, 24.
compound fracture of femur treated with car-
bolic acid, 25.
Morton, W. T. G.: demonstration of anaesthetic
property of sulphuric ether, 491.
Mould: on preserve as distinctly a vegetable as a
cabbage, 483.
Munich General Hospital :
treatment in, 248.
pyaemia and hospital gangrene banished, 248,
500.
erysipelas rare and mild, 248, 500
Muscle, involuntary: fibre cells of, discovered by
Kolliker, 529.
Muslin gauze. See Gauze.
J. Lister’s labours in
J. J. Lister’s improve-
effects of antiseptic
Naegeli (Munich) : bacteria cannot develop in con-
centrated organic solutions, 290 (footnote).
showed that more concentrated an organic
solution the less easily bacteria develop in it,
355-
Naevi: injection of perchloride of iron or tannin
produces subcutaneous sloughs which are
absorbed with suppuration, 93.
Necrosis: acute case of, treated on antiseptic
system, 65.
INDEX TO VOLUME II
Nerve, sympathetic, in neck: section of, causing
turgescence of vessels of ear, 529.
galvanic stimulation of distal end causes pallor,
529.
Nervous system :
147. F :
Nitric acid: in treatment of hospital gangrene, 17.
Nitrous oxide gas: anaesthetic properties of, dis-
covered by Humphry Davy, 491.
its use in short operations and tooth extractions,
492.
Nussbaum, v.: antiseptic treatment introduced by,
into Munich General Hospital, 248, 500.
his testimony as to revolution in salubrity of
hospital brought by antiseptic treatment, 249
(footnote).
inflammation produced through,
Oakum: as antiseptic dressing, 168.
contains no carbolic acid, but creosote and
probably other antiseptic hydrocarbons, 168.
advantages of, over lac plaster, 168.
applied to sore thoroughly washed with anti-
septic lotion and covered with protective
nearly approaches ideal dressing (1871), 168.
disagreeable to many owing to tarry smell, 160.
what it is, 169.
modified form of, made by steeping muslin gauze
in carbolic acid, resin, and paraffin melted
together, 169 (and footnote).
Oedema: ‘doughy’ swelling of, caused by plasma
forced through capillaries by venous obstruc-
tion, 533.
Oedema, serum of: is normal plasma, 539.
Ogston: micrococci in acute abscesses, 347, 501;
classified by him into streptococci and staphylo-
cocci, 501.
no organisms found in discharges of carbolized
dressing if changed daily, 294.
Olecranon: compound fracture of, treated anti-
septically, 140, 151, 155; firmly united in five
weeks, 155.
Olecranon: cases of ununited fracture of, success-
fully treated by wiring, 453, 454, 455, "468, 469.
Omalgia: advantages of actual cautery in, 373,
374-
Onychia: ‘amykos’
used in, 227.
Operation: seldom fatal since introduction of
antiseptic system (Saxtorph), 248.
conditions of: sponges, instruments, surgeon’s
hands and patient’s skin must be aseptic, 351.
entourage of seat of, must be protected by anti-
septic solution, 351.
when no chemical antiseptic at hand, 355.
boil sponges, silk ligatures, and instruments, 355.
cleanse hands and skin with soap and water, 355.
use silver wire, silkworm gut or horsehair, for
stitching, 355.
Operations: importance of keeping instruments
antiseptic in, 219.
Operations from time immemorial prohibited:
successfully performed under antiseptic sys-
tem, 341.
Operation wounds :
ment of, 44.
provision of condition making them on a par with
subcutaneous injuries, the ideal of surgery, 292.
Orbit: extravasation of blood into, causing
suppuration without external wound, 21
(boracic acid) successfully
use of carbolic acid in treat-
INDEX TO VOLUME II
Organisms: excluded from wound by scab mechani-
cally, 83; by metallic plaster owing to germ
poison in surrounding dressing, 84.
relation of, to septic energy of air, 47.
development of, caused by air dust, 47.
with most resisting spores cause no trouble in
surgical work, 351.
Organisms, living atmospheric: exclusion of, during
operations impossible, 342; but no harm
caused by their entrance, 342.
Organisms, pyogenic: not abundant in dust of
hospitals, 344.
‘Organization’: process of, in blood, lymph and
catgut, 118.
of clots and sloughs under antiseptic treatment,
B53.
Os frontis, fracture of. See Fracture.
Ovariotomies,: G. Granville Bantock’s remarkable
series of, 335.
Ovariotomy: catgut for tying pedicle must be
of specially strong quality, 271 (footnote).
successful results without use of antiseptics, 275.
objections to use of antiseptic method in, 275.
without antiseptic precautions, successful pos- |
sibly because no septic organisms have been
introduced into peritoneum in condition
capable of developing in diffused serum, 270.
explanation of success of operation without
antiseptic precautions, 285.
limited abscess after, 286.
Ovariotomy, antiseptic: not in author’s opinion
a touchstone of antiseptic principle, 275.
Oxygen, atmospheric : not of itself cause of putrefac-
tion, 480; held by Liebig to be primary cause
of putrefaction, 497.
Paget, James: stasis of blood in capillaries of
bat’s wing resulting from irritating applica-
tions, 518.
Palm: fetid suppurating wound of, treated by
injection of saturated watery solution of
carbolic acid, 83.
Paraffin cerate: as vehicle for carbolic acid, 71.
crumbles and becomes useless in situations such
as groin, 71.
Paré, Ambroise : his advocacy of ligature for arrest
of haemorrhage, 379 (footnote).
urged ligature in preference to cautery for arrest
of haemorrhage in amputation, 380.
his teaching failed for a long time to influence
surgeons, 380.
Parotid tumour.
PARE It,
See Tumour.
THE ANTISEPTIC SYSTEM (1867),
ie
PART IV. SURGERY (1854), 373.
PART V. ADDRESSES (1869), 477.
Paste. carbolic acid: wound in compound fracture
closed by, 28
in treatment of abscess, 43.
as a dressing, 68.
its inconvenience, 68.
See also Carbolic.
Pasteur: decomposition of organic substance by
exposure to atmosphere, 2.
septic property of atmosphere due to organisms,
37:
researches on living organisms in atmosphere, 47,
484.
vinous or butyric fermentation in same sac-
579
Pasteur (continued) :
charine solution produced by different organ-
isms, 47.
modification of experiment illustrating germ
theory of putrefaction, 54.
experiment on putrefaction by boiling liquid in
flask with attenuated and contorted necks,
484.
smell of suet resulting from oxidation of fatty
matter in boiled milk, 302.
on Koch’s method of cultivating bacteria on
solid media, 332.
showed putrefaction and other fermentative
changes to be due to micro-organisms, 340.
destroyed idea of spontaneous generation, 340.
showed that air of every inhabited place teems
with various microbes, 349.
his results confirmed by Committee of French
Academy of Sciences, 485, 486.
experiment on cause of putrefaction in urine,
486 (footnote).
work on fermentation, 492, 493, 494, 495, 497.
his demonstration of importance of micro-
organisms in economy of Nature, 494, 495.
influence of his work on surgery, 495.
his demonstration that putrefaction is fermenta-
tion caused by growth of microbes, 497.
his induction that all infective disorders are of
microbic origin confirmed, 502.
his recognition of importance of Koch’s
culture’ of bacteria, 503.
attenuation of virus by cultivation of bacterium
of fowl cholera, 504.
researches on hydrophobia, 506.
his work in bacteriology, 512.
his demonstration that putrefaction is caused
by growth of microbes, 542.
Pasteur’s germ theory: author’s experiments in
confirmation of, 499.
Pasteur’s solution: addition of drop of tap water
to, causes development of micro-organisms,
173;
‘ plate
277.
Patella, fracture of: letter (1895) on treatment of
a case of long standing, 471. See also Fracture.
Patella, fracture of long standing: wiring in two
stages without division of quadriceps, 472;
details of operation, 472, 473, 474; result of,
474, 475- ;
advice as to treatment of a case, 475.
disadvantages of division of quadriceps extensor
for approximation of fragments, 471 ; wiring
without such division, 471.
Patella, transverse fracture of :
with horsehair, 446.
recent cases of, treated by wiring,
462, 463, 464.
method of operating, 465.
importance of avoiding entrance of septic mis-
chief, 466.
case in which no operation was performed, 466,
467.
wired and drained
457, 458, 459,
osseous union after wiring, 450, 461, 463, 465.
remarks on method of treatment, 467, 408.
antiseptic treatment in, 460.
Patella, ununited transverse fracture of: treated
by wiring, 456, 457, 459, 4600, 461.
Patellar bursa, See Bursa.
‘Pathogenic bacteria’. See Bacteria.
Pathological researches ; author's early, 515.
580
Pegs, ivory: in treatment of ununited fracture,
partial absorption of, 16.
Pemberton: ligature of external iliac artery with
catgut prepared with chromic acid, III.
Penis: boracic lint as dressing after operations on,
233, 235.
cancer of, 233.
method of amputating, 235.
Perineum, wounds in: oily solution of carbolic
acid, useful application to, 70 (footnote).
Peritoneum: high vital power of, 277, 285, 286;
a favourable circumstance in abdominal sur-
gery, 277; illustrated by case of strangulated
hernia in which, eight hours after death, it
was impossible to find site of incision from
within, 277.
washing and drainage of, as practised by Lawson
Tait and Bantock are antiseptic measures, 335.
avoidance of direct application of strong anti-
septics to, desirable, 335.
water for washing out should be freed from
living organisms, 335.
washed out by Bantock with boiled water, 336;
a very weak solution of corrosive sublimate
would be better for purpose, 336.
Peritoneum, ligature made from strips of small
intestine of ox treated with carbolic acid and
used in a Calf, 93.
Petit, J. L.: improved tourniquet devised by, 381,
382.
method of amputation by ‘ double incision ’, 382
(and footnote).
Pfeiffer: bacillus of influenza, 502.
Phagocyte theory: explains much hitherto mys-
terious in relation of micro-organisms to
wounds, 334.
explains antibacteric influence of living tissues,
334; and use, without evil consequences, of
non-antisepticized silk ligatures, 334.
Phagocytes: discovered by Metchnikoff, 332 ; ex-
periments on action of, 333; absorb microbes
in wounds, 514.
Phagocytosis: process of, 350, 513.
the main defensive means of living body against
invasion of microbes of infective diseases, 513.
gets rid of dead microbes, 514.
explains healing of wounds without antiseptic
treatment, 514.
the doctrine completes theory of antiseptic sur-
gery, 514.
Phalanx of toe: removal of, 402.
Phalanges of hand: amputation of, 397.
Phenic acid. See Carbolic.
Phimosis: boracic lint as dressing after operation
for, 234.
Phlebitis, suppurative : produced by introduction
of piece of wood into femoral vein of dog
(Cruveilhier), 132.
Pigment in frog’s foot: aggregation of, under irrita-
tion, 524, 525, 526 (and footnote).
concentration of, under nervous influence, 525,
520.
diffusion of, in rare cases caused by irritant, 526
(footnote), 527.
Pigment granules,
mobility, 540.
may be living entities, 540.
effect of nervous influence on, 540.
effect of irritation on, 540, 541.
black: in ‘drog, «their, free
INDEX TO. VOLUME II
Pigmentary functions in frog, 524, 545.
experiments on, 524.
Pirogoff: amputation at ankle, 406, 407.
Pit burial: of paupers in churchyard close to
‘New Surgical Hospital’ (Glasgow Royal In
firmary), 125.
account of a pit, 125.
Dean of Guild’s computation of number of
decomposing bodies in pits, 126.
Plaster, adhesive: how made antiseptic, 168, 169
(footnote).
Plaster, lac:
note).
See also Lac.
Plaster, lead: as vehicle for carbolic acid, 71.
See also Lead.
Plaster, living:
surfaces, 2.
Plastic operations: on lower lip, boracic ointment
dressing after, 245.
Plate culture. See Culture.
Pleurisy, suppurative: caused by external wound
penetrating chest, 3.
Plymouth, Naval Hospital at: Bernard’s testi-
mony as to beneficial effect of antiseptic
treatment on atmosphere, 197.
Pneumothorax: caused by puncture of lung by
fractured rib, no inflammatory disturbance in,
as vehicle for carbolic acid, 71 (foot-
formed by granulations in raw
Be
caused by simple fracture of ribs, 60.
Polli: administration of sulphites in cases of
compound fracture as prophylactic against
pyaemia, 126, 542.
method tried by author without success, 542.
Pollock: amputation at knee-joint, 411 (footnote).
Popliteal aneurysm. See Aneurysm.
Poulticing of abscess: promotes putrefaction and
development of organisms, 347, 348.
Primary union after amputation: aimed at by
Celsus, 379.
‘Protective’ in antiseptic dressings, 143, 167;
composition of, 144, 145, 167, 192, 193;
illustrations of its usefulness, 146; why not
employed at first dressing, 150; prevents
‘antiseptic suppuration ’, 152; healing more
rapid in proportion to efficiency of, 154; pre-
paration of, 167 (footnote), 184, 185, 192, 193 ;
oiled silk acts well till moistened, 184; at-
tempts to perfect, 184; new method of pre-
paring, 185; must be unstimulating to
tissues and impermeable to antiseptic, 185 ;
must never extend beyond gauze, 267.
Protective, oiled silk: use of, in antiseptic dressing,
202.
shields blood-clot in wound from stimulation of
antiseptic, 265.
Protective, vulcanized caoutchouc :
charge under, 184.
Pruritus ani: use of boracic acid in, 228.
Pseudopodia of white corpuscles, 512.
Purification of hands and instruments by germi-
cidal means wiser than to trust to mere cleanli-
ness, 335.
Purmannus, in Chirurgia Curiosa (1696), describes
amputation of legs by a sort of guillotine, 380 ;
but prefers old way of cutting through flesh
with knife and bone with saw, 380.
Pus: in ordinary abscess formed as result of excited
nervous action, 40.
stench of dis-
INDEX TO’ VOLUME II 581
Pus (continued) :
pent up in abscess the stimulus which maintains
suppuration, 42.
formed by granulations, 49.
author’s researches on, in case of pyaemia, 515,
5106.
Pus corpuscles: in pyaemia, not ordinary leuco-
cytes, 541.
Pus formation: not exclusively due to emigration
of leucocytes, 542.
often caused by proliferation of cells, 542.
PUTREFACTION AND FERMENTATION, AN
INTRODUCTORY LECTURE ON THE
CAUSATION OF (1869), 477.
Putrefaction: germ theory of, 54, 172, 479; the
guiding principle of antiseptic system, 172, 4709.
evil effect of, on tissues of wound, 2.
due to living germs in atmosphere, 2.
vibrios chief agents in, 47.
acrid salts resulting from, multiplied and
intensified by self-propagating ferments, 49.
experiments illustrating germ theory of, 54.
complete exclusion of air not in itself security
against, 54.
not produced by access of air if germs have been
filtered or killed, 54.
experiment on urine in flasks with bent necks,
illustrating germ theory of, 55, 173.
and equivocal generation, 57.
in amputation stumps cannot always be avoided
even with antiseptic treatment, 130.
and suppuration, reply to criticisms, 146.
not held by author to be sole cause of suppura-
tion, 146.
products of, excite superficial suppuration in a
sore treated with water-dressing by chemical
stimulation, 149; often cause death by irrita-
tion and blood poisoning before suppuration is
established, 149.
Pasteur’s experiment of boiling putrescible
liquid in flask with attenuated and contorted
neck, 173; author’s repetition of experiment in
modified form, 173.
caused not by atmospheric gases, but by dust in
atmosphere, 175, 178; this the guiding prin-
ciple in antiseptic treatment, 178.
decomposition without, illustrated by stench of
discharge under vulcanized caoutchouc pro-
tective, 184; and by foul smell of serous
discharge soaked into antiseptic gauze, 188.
prevented, not corrected, by antiseptic treat-
ment, 216.
occasional occurrence of, owing to application of
antiseptic gauze dry, 260.
in wounds not treated antiseptically due rather
to septic matter in concentrated form than to
diffused condition in which it exists in air and
water, 279; this suggests question whether
spray is necessary, 2709.
in blood-clot in living body, experiments on, 282,
283, 284.
diffusion of chemically irritating products of,
beyond limits of septic process, 284.
in wounds, a general occurrence in pre-anaesthetic
periods, 340; possibility of preventing, by
destruction of microbes, 340.
prevented by phagocytosis, 514.
caused by growth of micro-organisms, 340.
not induced by mere inflammation, 481.
Putrefaction (continued) :
similarity in process to vinous fermentation, 482.
author’s experiments on cause of, in urine, 486
(and footnote), 487, 488.
experiment previously performed by Pasteur,
486 (footnote).
caused by growth of micro-organisms, 494.
a great evil in surgery, 497.
prevention of it hopeless while thought to be
caused by atmospheric oxygen, 497.
shown by Pasteur to be fermentation caused by
growth of microbes, 497.
not the only evil of microbic origin to which
wounds are liable, 501, 542.
and fermentation of sugar, parallel between, 48o.
Schwann’s researches into causes of, 479.
See also Germ.
Putrefactive changes: caused by air dust, 47.
Putrefying material: must act for three or four
days on tissues before suppuration is set up, 150.
Putrescent organic matter: induces suppuration
by acting as chemical stimulus, 4o.
Putty, carbolic acid: method of preparing, 33.
in treatment of compound fracture, 36, 39.
in antiseptic treatment of incised wounds, 36.
in treatment of large wounds, 38.
as a dressing, 68.
its inconvenience, 68.
maintains constant antiseptic action, 70.
Pyaemia: frequency of, in Glasgow Royal In-
firmary before introduction of antiseptic
treatment, 45, 541.
in ‘New Surgical Hospital’ (Glasgow Royal In-
firmary), 123; most prevalent in ground-floor
wards, 124.
used to occur principally in cases of compound
fracture and major amputations, 126.
sulphites administered internally in cases of
compound fracture as prophylactics against,
126; no distinct evidence of advantage from
this practice, 126.
no case of, in compound fracture since introduc-
tion of antiseptic system, 127.
mortality from, in major amputations before
antiseptic period, table of cases, 128 ; during
antiseptic period, table of cases, 128; com-
parison of results, 129, 130.
occurrence of, in case of injury of hand through
neglect of antiseptic precautions, 1 32.
no case of, in author’s wards in Edinburgh Royal
Infirmary (1870), 159.
prevalence of, in Munich General Hospital, 248;
banished by antiseptic treatment, 248, 500.
practically banished from Surgical Hospital at
Leipzig, since introduction of antiseptic
system, 249.
banished from Volkmann's c/inigue at Halle, since
introduction of antiseptic system, 250.
practically abolished in Berlin Charité Hospital,
since introduction of antiseptic system, 252.
almost entire disappearance of, in Magdeburg
Surgical Hospital, since introduction of anti-
septic treatment, 252 (and footnote).
case of, after excision of wrist, 439, 440.
author’s researches on pus in case of, 515, 5106.
author’s experiments showing that introduction
of septic material into vein causes pus forma-
tion, 541.
relation of suppuration of blood clot to, 541.
582
Pyaemia (continued) :
Polli’s method of prophylaxis by internal admi-
nistration of sulphite of potash, 542; this
tried by author without success, 542.
abortive attempts to prevent contagion of, 542.
Pyaemia, spurious: fatal case of, after removal of
breast for cancer, 293.
Pyogenic membrane: no risk from rough treat-
ment of, 33.
forms pus only because subjected to some
preternatural stimulus, 34, 42 ; ceases to do so
after antiseptic opening of abscess, 34, 42.
empties abscess cavity by contracting after open-
ing, 34.
forms pus only in response to stimulation, 42.
ceases to develop pus corpuscles when freed from
irritation of pent up pus, 48.
Pyogenic micrococci: invariably present in acute
abscess, 347.
Pyogenic organisms :
hospitals, 344.
not abundant in dust of
Ravaton (Landau): method of amputation by two
flaps, 384.
Rays, X. See Rontgen.
Rectum abscess. See Abscess.
Rectum, abscess beside. See Abscess.
Reef knot, 393.
Revaccination : importance of, 505.
not recommended to be compulsory by Vaccina-
tion Commission on account of difficulties
foreseen, 505.
no difficulty in carrying out compulsorily in
Germany, 505; penalties by which it is en-
forced, 505, 506.
Reverdin: his principle of skin grafting, 230.
Rib: removal of portion of, for empyema, success-
fully dressed with sero-sublimate gauze,
307.
Ribs, simple fracture of. See Fracture; simple.
Richardson, Benjamin Ward: apparatus for pro-
ducing carbolic spray, 166.
apparatus for local anaesthesia used for spraying
carbolic acid on field of operation, 180, 181,
182; mode of using, 181 ; can be worked by
surgeon himself, 181.
local anaesthetization by freezing with ether
spray, 222.
his Astley Cooper Prize Essay on coagulation of
blood, 535.
ammonia theory of coagulation, 535.
Rodent ulcer. See Ulcer.
Rolleston, Professor: suggests use of carbolized
oil as lubricant for instruments introduced
into bladder, 212 (footnote).
Rontgen rays: discovery of, 480.
their power of passing through
opaque to ordinary light, 489, 490.
their use in surgery, 490; illustrated by case of
injury to elbow, 490.
instances of foreign bodies revealed by, 490.
application to medicine, 491.
Rosalane, pure: as dye for double cyanide of
mercury and zinc, 329.
its advantages as dye for double cyanide gauze,
361, 362.
its chemical composition ascertained by Perkin,
361 (footnote).
mode of use, 361 (footnote).
substances
INDEX TO VOLUME II
Roux: use of diphtheria antitoxin, 510.
Roux and Yersin: toxins of bacteria in diphtherial
membrane, 507, 508.
Royal Microscopical Society: letter to President
giving account of J. J. Lister’s labours on
improvement of achromatic microscope, 543.
Ruffer, Armand: confirmation of Metchnikoff’s
discovery of phagocytes, 332 (footnote).
Rupture. See Hernia.
Sal-alembroth: description of, 310.
antiseptic properties of, 310.
more efficacious and less irritating than mercury
bichloride, 311.
disadvantages of, 312.
author never satisfied with it as a dressing, 312.
satisfactory results of, used moist with efficient
germicidal solution, 316.
Sal-alembroth gauze. See Gauze.
Salicylic acid: used by Thiersch as external dress-
ing instead of carbolic acid, 249.
not so powerful an antiseptic as carbolic acid,
295.
Salicylic cotton wool: soaked with serum and
inoculated with putrid blood, stinks after a few
weeks, 305.
Sanderson, J. Burdon: septic ferments in water,
220, 220.
Sarcoma of femur: amputation for, 413.
Saxtorph, Professor: letter giving his experience
of beneficial effect of antiseptic system on
healthiness of surgical hospitals, 156.
successful extraction of fragment of head of tibia
from head of knee-joint under antiseptic
treatment, 157.
his careful observation of antiseptic system and
thoroughness in carrying it out, 159.
his testimony as to influence of antiseptic system
on healthiness of surgical wards, 197.
his testimony as to effect of antiseptic treat-
ment on healthiness of Copenhagen hospitals,
247.
healing of wounds of scalp, contused wounds,
compound fractures, and wounds of joints,
under antiseptic dressing and drainage tubes,
248.
value of antiseptic treatment in amputations and
excisions, 248.
successful treatment of abscesses connected with
diseased bone in antiseptic method, 248.
Scab: excludes organisms mechanically, 83.
Scabbing, healing by : in compound fracture, 74.
possible risks of, 74; attempts to get rid of
these, 75; of an ulcer by, 147.
cicatrization without suppuration beneath a
piece of tin a novel mode of, 82.
Scalp, sebaceous cysts of: dressing by cyanide
gauze after removal of, 322.
Scalp wounds: antiseptic treatment of, 139, 151.
details of dressing, 139, 140.
Schede (Hamburg): occurrence of erysipelas under
iodoform dressings, 295.
Schmidt: showed that normal liquor sanguinis
does not contain fibrine in solution, but only
fibrinogen, 538.
Schulze, Max: movements of animal protoplasm,
525 (footnote).
Schwann: yeast plant discovered by, in 1837, 479,
493-
INDEX TO VOLUME IT
Schwann (continued) :
experiments showing that putrefaction is caused
by organisms springing from germs in air, 479.
researches on putrefaction of meat, 493.
fibrinogen in normal liquor sanguinis, 538.
SCIENCE AND THE HEALING ART, ON THE
INTERDEPENDENCE OF (1896), 489.
Scultetus: depicts (1655) amputation of hand by
chisel and mallet, 380.
Sebaceous cysts. See Cysts.
Sédillot : multiple abscesses in lungs produced by
introduction of pus into veins of an animal,
(ride?
Semon, Felix: pressure on anterior wall of trachea
by goitre, 102.
Senile gangrene. See Gangrene.
‘Septic’: what is included in the term, 288 (foot-
note).
Septic agencies: the cause of disasters of surgery
in the past, 288.
Septic diseases: germ theory of, established, 323.
Septic element: suppression of, in wards makes
less space necessary, 291.
Septic energy of air: proportional to abundance of
organisms in it, 47.
Septic ferments in water, 225, 226.
nature of, 226.
experiments showing that in water they are
suspended particles not equally diffused in the
liquid, 226, 227.
Septic material: even if assumed to be a chemical
ferment, must be dealt with by antiseptic
methods, 219 (footnote).
Septic particles: in dust, are self-propagating, and
their energy is destroyed by heat and various
chemical substances, 178.
Septic property of atmosphere: due to organisms,
37:
Septicaemia: avoided by antiseptic treatment
(Saxtorph), 248.
diminution of, in Magdeburg Surgical Hospital
since introduction of antiseptic system, 253
(footnote).
Sero-sublimate gauze. See Gauze.
Serous effusions, chronic: cause of obstinacy of,
223.
antiseptic evacuation of, by aspirator, 223.
Serum: decomposition of, cause of suppuration in
wounds, 37.
accumulation of,
disturbance, 221.
Serum, albumen of: action of corrosive sublimate
on, 299.
Serum, antitoxic. See Antitoxic.
Serum, blood: not so favourable a soil for growth
of micro-organisms, as once believed by
author, 277.
effects of corrosive sublimate on, 302, 303.
addition of, to corrosive sublimate in preparation
of gauze, 304.
(from horse) inoculated with putrid blood as
a test of antiseptic power in dressings, 301,
_ 302, 303, 304, 305.
Serum of blood-clot: no putrefaction in, caused
by addition of water, 278.
Serum with corpuscles (from cow): mixed with
blood corpuscles as test of antiseptic power of
dressings, 305, 306; inoculated with putrid
blood as test of antiseptic power, 305 ; failure
keeping up inflammatory
583
Serum with corpuscles (from cow) (continued) :
of sublimated wood wool and of 1 per cent.
sublimated wool under this test, 306; test
stood by 10 per cent. sublimate wool, 306;
everything fails under this test except
stronger sublimate preparations and carbolic
gauze, 3006.
Serum, normal: bacteria diffused by means of
water incapable of developing in, 278; sug-
gested explanation of fact, 278, 279.
not putrefied by addition of small quantity of
water, 280.
Serum, normal blood: not favourable for growth
of attenuated bacteria, 350.
Serum, sublimated: for impregnation of various
substances used as dressings, 306.
as a dressing: satisfactory results of, 309.
defects of, 309.
sal-alembroth (double salt of mercury and
chloride of ammonium) as substitute for, 310.
Serum, undiluted healthy: bacteria after wide
diffusion by means of water incapable of
development, 278.
Sewage of Carlisle: effect of carbolic acid on, 3.
‘Sharp spoon’: for scraping carious bone, intro-
duced by Bruns, 251.
successful use of, by Volkmann in combination
with antiseptics, 251.
author’s adoption of, 251.
Sharpey, W. : recommends use of word ‘ inhibitory’
as equivalent for Hemmungs-Nervensystem,
2096.
inspired author with love of physiology, 515.
his recommendation to author to visit Edinburgh,
Bf
greatly pleased by author’s experiment showing
that vaso-motor function for hind legs of frog
is discharged by most anterior, as well as
entire posterior part of spinal cord, 530.
Shellac. See Lac.
Shock in operations: abolished by anaesthesia, 492.
Shoulder-joint : pain in, cured by application of
actual cautery (Syme), 373, 374, 375.
amputation at, safer than at knee, 397.
methods of, 400.
Siegle’s steam inhaler: carbolic spray producer
acting on principle of, 258.
Silk ligatures: cut short in stump may appear
after healing of wound (Lawrence), 92; or
encapsuled in nodules in cicatrix with occur-
rence of suppuration, 92.
not permanently embedded where introduced,
but when broken up may make way to surface,
92.
objection to, as a possible cause of suppuration,
92.
used by many surgeons under antiseptic treat-
ment, 102; results not always satisfactory,
102; aninstance of this (Clutton), 102.
Silk ligatures, non-antisepticized : use of, without
evil consequences explained by phagocyte
theory, 334.
Silk sutures: made antiseptic by steeping in a
mixture of beeswax and carbolic acid, 139.
carbolized, preparation of, 219 (footnote).
Silk sutures (non-antiseptic): irritating properties
of, 534, 535:
thread: disadvantages of, as ligature for
arteries, 86, 87.
Silk
584
Silk thread (continued):
author’s notion that if ligature is steeped in liquid
capable of destroying septic organisms in inter-
stices, it would be encapsuled or absorbed, 87.
leucocytes may creep between fibres of, and
destroy microbes there, 335.
Silk thread, antisepticized: disintegration and
partial absorption of, after ligature of artery,
90; causing mechanical disturbance in parts
in contact therewith, 91.
Silkworm-gut: in reality unspun silk, 84 (footnote).
Silver-wire stitches: in operations for harelip, 245.
Simon (Heidelberg): first pointed out importance of
‘stitches of relaxation’, 241 (footnote).
Simpson, James Young: introduction of chloro-
form as substitute for ether in surgery, 492.
use of chloroform in confinements, 492.
Sims, Marion: his success with silver wire in
gynaecology, 534.
Sinus: after incision of abscess, antiseptic probing
of, 36.
Sinus forceps. See Forceps.
Sinuses: putrefaction in track requires special anti-
septic treatment, 195 (footnote).
Sinuses in amputations and excisions: injection of
chloride of zinc into, 131 (footnote), 214.
failure of chloride of zinc owing to antiseptic not
penetrating into recesses, 251.
Volkmann’s successful use of sharp spoon before
application of antiseptic lotion, 251 ; author’s
adoption of this plan, 251.
Sinuses from carious disease of bone: antiseptic
treatment of, 214; use of boracic ointment in,
246.
Sinuses after excision of wrist: persistence of, 435,
436, 437- Hy 21,
Sinuses, septic: restoration of aseptic conditions in,
338.
value of iodoform in treatment of, 357.
Skin of patient: purification of, before operation,
354-
Skin-grafting: boracic acid particularly useful for,
230.
manner of carrying out, 230, 231, 232.
its effects in promoting healing of a sore, 440.
a living dressing, 449.
Sloughing: in wounds, 2.
Sloughs, decomposing: cause of local inflamma-
tion and febrile disturbance after injuries, 37.
disturbance in tissues around, caused by, 48.
Small-pox: outbreak of, in Edinburgh, accom-
panied by epidemic of erysipelas, 241 (footnote),
255-
analogy between vaccination against, and pro-
tection against fowl cholera by its attenuated
virus, 504.
extremely rare in Germany, 506.
Snake poison: antidotes against (Calmette, Fraser),
510.
Solvent: energy of action of any substance upon
tissues depends on tenacity with which it is
held by, 498.
Sore, open: healing by cicatrization without
suppuration or even granulation something
new in history of surgery, 153.
_ healing of, under boracic acid dressing, 230.
Spence, James: method of amputation, 390.
amputation through calf, 409.
Splint: for hand after excision of wrist, 432.
INDEX TO VOLUME II
Sponge, carbolized: use of, in antiseptic treatment
of wounds, 224.
first used by Syme, 224 (footnote).
kept steeped in carbolic lotion in hospitals, 225.
method of preparation in private practice, 225.
Sponges: purification of, for abdominal operations
by Bantock and Tait, 335.
wrung out of sulphurous acid, used by Bantock
in cleansing peritoneum, 335.
carbolic acid best purifying agent for, 351.
author’s method of purifying for private opera-
tions, 353.
need not be discarded for sterilized cotton wool,
53-
Peaking of, during operations, 354.
Spontaneous generation: idea of, demolished by
Pasteur, 340, 494; objections to doctrine of,
482, 483, 484. ;
Spoon, sharp. See Sharp.
Spore-bearing bacteria: resist all known germici-
dal agents that could be used in operations, 341.
do not cause mischief in wounds, 341; an
exception to this, 341 (footnote).
Sporeless bacteria: killed by carbolic acid, 341,
342-
Sporeless micrococci: our enemies in surgery, 351.
Spores: organisms with most resistance cause no
trouble in surgical work, 351.
Spray, carbolic acid: use of, to prevent admission
of putrefactive organisms to wound in opera-
tions, 166, 170, 180, 181.
dispenses with necessity of washing wound with
antiseptic lotion, 170.
useful in stitching wounds and in changing dress-
ings, 170.
reduction of strength to 1 in 100, 180; ad-
vantages of this reduction for surgeon and
for patient, 180.
illustration of its use in opening a psoas abscess,
181.
makes safety in ligature of arteries with anti-
septicized catgut a matter of certainty, 190.
I in 40 carbolic acid solution recommended, 206.
absurdity of using when wound communicates
with mouth, 245.
none would rejoice more than author if it could
be got rid of, 260.
importance of its being directed on wound, 260 ;
instance of neglect in this particular, 261.
importance of proper direction in removal of
drainage tubes, 267.
is it necessary ? 2709.
the least important of antiseptic means, 279.
if apparatus not at hand, surgeon should still
attempt to obtain antiseptic results, 270.
author in view of his results does not feel justified
in abandoning it except on perfectly established
grounds (1881), 280.
if proved that idea of atmospheric contamination
of wounds is baseless, he would joyfully aban-
don it, 280.
irrigation advocated instead of, by Bruns, 280
(footnote).
author ashamed (1890) he ever recommended it,
for destruction of microbes in air, 336.
untrustworthiness of, 336.
illustrated by operation for empyema, 336, 337-
abandoned by author in 1887, 337.
did not destroy microbes in air but owed what-
INDEX TO VOLUME II
Spray, carbolic acid (continued) :
ever good it did to properties as irrigator, 336,
342-
can be dispensed with, 350.
Spray, Fort mit dem (Bruns), 280.
Spray: Keith’s ovariotomies under, 276; after-
wards abandoned by him, 276 (footnote).
Spray-producer: Richardson’s, 166, 180, 181, 182.
author’s, for large operations, such as ampu-
tation of hip or thigh, 181 ; description of, 182;
improvement in, 258.
Spray-producer, steam :
inhaler, 206, 258.
1 in 30 carbolic solution required to produce
strength of I in 40, 207.
necessity of ascertaining proportion between
steam and solution, 207 (footnote); mode of
determining this, 207.
Sputum, phthisical: Crookshank’s experiments on
tubercle bacilli in, 352 ; these show destructive
power of carbolic acid, 352, 353.
Squire (Plymouth): his treatment for loose car-
tilage in knee-joint, 194.
Stang (Storweg, Norway): ‘aseptin’ and ‘ amy-
kos ’, 227 ; boracic acid the active principle in
these substances, 227.
Staphylococci: killed by carbolic acid, 341, 342.
in acute abscesses, 501.
Staphylococcus pyogenes aureus: its resistance to
germicidal action of corrosive sublimate, 343.
most frequent cause of suppuration in man, 343,
on principle of Siegle’s
351.
killed by carbolic acid, 344 (Crookshank, in foot-
note).
has great resistance, 351.
killed more rapidly in surgical work by carbolic
acid than by mercury bichloride, 351.
Stasis of blood. See Blood.
‘ Stimulus of necessity’ (John Hunter): is stimulus
of putrefying substance, 241.
Stitches, button. See Sutures.
‘Stitches of relaxation’: 241.
importance of, first pointed out by Simon of
Heidelberg, 241 (footnote).
Stitches, horsehair: use of, in operations for hare-
lip, 245.
Stitches, silver-wire :
harelip, 245.
Strapping, antiseptic: preparation of, 168, 169 (foot-
note).
Streptococci: killed by carbolic acid, 341, 342.
in acute abscesses, 501.
Streptococcus of erysipelas: destroyed by weak sub-
limate solutions, 344 (Crookshank in footnote).
the cause of erysipelas, 501, 502.
Streptococcus pyogenes: destroyed by weak solu-
tion of corrosive sublimate, 344.
Stump. See Amputation.
Sublimate, corrosive. See Corrosive.
Sublimate serum, See Serum.
Sublimate lotion: rags steeped in, as an emergency
dressing, 319.
development of microbes prevented by, 343.
Sublimate wood wool: preparation of, 297.
experiments as to effects of, on blood, 300, 301,
302.
its effects on milk, 302.
gives compound with serum which retains pro-
perties of corrosive sublimate, 302.
LISTER IL
use of, in operation for
585
Sulphate of chromium. See Chromium.
Sulphite of potash : internal administration of, as
prophylactic against pyaemia, 542.
Sulpho-chromic catgut. See Catgut, chromic.
Sulphurous acid gas: diffused through cotton wool
as an antiseptic dressing, 176.
Sulphurous acid lotion: as an antiseptic wash for
raw surfaces, 180.
Suppuration: not always due to micro-organisms,
216.
observations on conditions of, 1.
in wounds, 2, 37.
carbolic acid as a preventive of, 3.
caused by stimulating action of carbolic acid, 8,
II, 50, 147.
not mischievous, II.
in extravasated blood without external wound,
21;
in compound fracture of femur, independent
of atmospheric influence, 21, 26.
caused by decomposition due to influence of
atmosphere, 37.
appearance of, not a sign of failure of antiseptic
treatment, 39.
not caused in granulations by contact of foreign
body, 40.
may be induced by carbolic acid acting as
chemical stimulus, 40.
different effects of carbolic acid and decom-
position in regard to, 41.
may be produced by antiseptics but only on
surface to which they are applied, 49.
from stimulating action of antiseptic, mode of
avoiding, 50.
putrefaction not held by author to be sole
cause of, 146.
produced by long-continued action of carbolic
acid on tissues, 147.
may be caused through nervous action or by
noxious agents (stimulating salts or chemical
stimuli), 147.
causes of, exhibited in diagrammatic form, 149
(and footnote).
element of time in, 150.
cannot be induced by any stimulus in healthy
tissues, 150.
granulation must precede, 150.
may occur without septic organisms, 216.
not stopped by carbolic acid by any specific
agency, 265.
i pre-anaesthetic days, 293.
author’s former view that it was caused by
tension of pent-up liquid operating through
nervous system disproved, 347.
Staphylococcus pyogenes aureus most
cause of, in man, 343, 351.
without putrefaction: occurrence of, 501.
formerly an inevitable attendant on
every wound, 518.
author’s early doctrine that it was due to decom-
position of organic liquids, §35.
Suppuration: ‘ Antiseptic’. See Antiseptic.
Suppuration and granulation, 82.
Suppuration, inflammatory: different from that
produced by chemical stimulation, 40.
Suppuration of joints: spontaneous cure of, under
antiseptic system, 48.
Suppuration, septic: cases of, after operations
performed antiseptically, 293.
frequent
nearly
Qq
586
Suppuration of vertebrae: spontaneous cure of,
under antiseptic treatment, 48.
SURGERY, THE ADDRESS ON (delivered at the
Annual Meeting of the British Medical Associa-
tion, 1871), 172.
Surgery: antiseptic principle in, 37.
revolutionized by introduction of antiseptic
system, 34I.
Surgery, clinical: remarks on the teaching of, 441.
importance of, 478.
Syme’s method of demonstrations in operating
theatre, 479.
Surgical Hospital. See Hospital.
Surgical teaching, clinical: in Edinburgh superior
to that in London, 451.
personal explanation on the subject, 451, 452.
Surgical wards: unhealthiness of, caused by
emanations from sores, 135.
Suture, button: description of, 241.
use of, 241, 242; after removal of breast, 273.
Suture, silver: in gynaecology (Marion Sims), 534.
tried by author in general surgery, 534.
used afterwards by Syme till introduction of
antiseptic silk, 534.
Sutures, catgut. See Catgut.
Sutures, silk. See Silk.
Sweden: discovery of new antiseptic substance
(boracic acid) in, 227.
Syme: method of removal of tongue for cancer, 53;
fatality of compound dislocation of ankle, 137 ;
led to regard amputation or excision as best
treatment, 137.
treatment of irreducible hernia, 191.
his wards in Edinburgh Royal Infirmary, 197.
situation of ligature of femoral artery for po-
pliteal aneurysm, 218.
diffuse aneurysm of axillary artery treated by
‘old operation ’, 286; the case as illustration
of action of blood-clots in preventing putre-
faction, 287. :
cases of articular disease exemplifying advan-
tages of actual cautery, 373, 374, 375, 370, 377.
actual cautery introduced into Great Britain by,
377:
modification of circular method of amputation of
leg, 385; adaptation of, to thigh, 385.
excision of metacarpal bone, 308.
method of amputation at shoulder-joint, 4o1.
amputation at ankle, 404, 405, 406.
amputation through calf, 409.
method of clinical surgical demonstration in
operating theatre, 452, 478.
inclined to think that amputation should be
performed in all compound fractures of leg, 495.
author fascinated by, 517.
a second house surgeoncy under, 517.
superiority of histreatment of wounds tothe ‘water
dressing ’ at University College Hospital, 517.
his method of dressing wounds, 517.
Sympathetic nerve. See Nerve.
Synovial effusions: cause of obstinacy of, 223.
antiseptic evacuation of, by aspirator, 223.
Tait, Lawson: success in abdominal surgery
achieved without antiseptic treatment, 335 ;
_ this a stumbling-block to some, 335.
Tait, Peter Guthrie: assists author in experiments
on dust in atmosphere by means of beams of
condensed sunlight, 175.
INDEX TO VOLUME II
Tannic acid: catgut prepared with, too rapidly
absorbed, III.
Tarsus: amputation through, 404.
Tchistovitch: confirmation of Metchnikoff’s dis-
covery of phagocytes, 332.
Teale (Leeds): method of amputation of leg, 133,
408.
plan of introducing pieces of flannel into socket
of artificial limb, 133.
method of amputation of penis, 235.
advantages of anterior flap in amputation, 387 ;
description of his method, 387; its drawbacks,
388, 380.
Tendon ligatures, unasepticized: tried and found
unsatisfactory, 92.
Tension: next to putrefaction the commonest
cause of inflammation in surgical practice, 223.
Tetanus: rendered much less frequent by anti-
septic treatment, 255.
treated with antitoxic serum, 509, 510.
conditions not favourable, 510.
Tetanus bacillus: forms toxin which poisons
system, 508.
Thiersch : first introduced antiseptic treatment in
Germany, 249; his testimony to the value of
antiseptic treatment, 249 (footnote).
his satisfactory results as regards salubrity of
hospitals, 249.
salicylic acid used by, as external dressing
instead of carbolic acid, 249.
carbolic acid used by, for spray and lotion, 249.
believes that erysipelas is not influenced by
antiseptic treatment, 249 (footnote).
Thigh : amputation of, 411, 412, 413,414. See also
Amputation.
Thorax: penetrating wound of, 61.
Thumb: amputation of, 398 (and footnote).
Thyroid vessels: circumferential ligature of,
before removal of goitre, 102.
Tibia: acute necrosis of, treated antiseptically
without exfoliation, 66.
chronic inflammatory thickening of lower part
with sinus, antiseptic excavation of, 267 ;
cavity filled by organization of blood-clot, 267 ;
progress of case, 268.
Tissues, dead: when protected from external
injuries, replaced by living, 365; this fact
suggested idea of catgut ligature, 365.
Tissues, injured: do not need to be ‘ stimulated ’,
but to be left alone, 144.
Tissues, living: healthy, prevent development of
bacteria, 280.
power of, to oppose bacteric development, 288.
antiseptic power of, 323: first pointed out by
author, 323; but antiseptic adjuvants also
important, 323.
influence of, in checking bacteric development
explained by phagocyte theory, 334.
bacteria introduced among, disposed of by
phagocytes, 350.
energy of action of any substance upon,
depends on tenacity with which it is held by
solvent, 408.
a most injurious agent operating mildly may
stimulate function without impairing power,
528 (and footnote).
no action of, required to keep blood liquid, 538,
539-
Toes, amputation of, 402.
INDEX TO
Torsion of arteries. See Arteries.
Torsion of vessels: in amputation, 394.
Torula cerevisiae: discovered by Cagniard-Latour in
1836, 479.
and independently by Schwann in following year,
479.
Tourniquet: invention of, 381 (and footnote).
Tourniquet, Esmarch’s elastic, 394, 395-
Tourniquet, screw: use of, in amputation, 394.
Toussaint: facilities afforded to author by, for
experiments at the Ecole Vétérinaire of Tou-
louse, 281.
Toxin, special :
508.
Toxins of bacteria: chemically altered and made
harmless by iodoform, 356.
Toxins: poisonous products of bacteria, 508.
absorbed into blood and diffused through body,
508.
Tube, drainage. See Drainage.
Tubercle bacillus: always present in pyogenic
membrane of chronic abscess, 347.
Yersin’s experiments on agents having germi-
cidal action upon, 351.
killed more quickly by carbolic acid than by
corrosive sublimate, 352.
as found in phthisical sputum, Crookshank’s
experiments on, 352; these show destructive
power of carbolic acid on, 352, 353.
need not be feared in surgical work if sponges
steeped in 1 in 20 carbolic lotion, 353.
discovered by Koch, 502.
Tuberculin: reaction produced by, followed by
improvement, 508.
apparent cures only transient, 508.
its use for diagnostic purposes in cattle, 500.
Tulley: achromatic object glasses made by, at
suggestion of Dr. Goring, 543.
his description of his microscope with acknow-
ledgement of indebtedness to J. J. Lister,
544; novelties in the instrument, 544.
Tumour, parotid: carbolized sponge used by
Syme after removal of, 224 (footnote).
Tyndall, John: investigation on dust in atmo-
sphere by means of beams of condensed light,
wis:
his proof that cotton wool filters air of contained
particles, 176, 178.
his lecture on Dust and Disease, 176 (footnote).
Typhoid fever: healing of intestinal ulcers in, 450.
formed by each poisonous microbe,
Ulcer: healing of, by scabbing, 147.
rapid healing and antiseptic dressing of, 448, 440.
Ulcer, rodent, of face: excision of, 240.
antiseptic treatment of, 2 243.
skin grafting after, 244.
cicatrization of, under boracic ointment, 243,
244.
Ulcers: treatment of, under gauze and protective,
196; illustrative case, 106.
boracic acid as an antiseptic dressing for, 220,
232.
Ulna, fracture of. See Fracture.
Union by first intention: under water dressing,
287.
rationale of rules of the older surgery in aiming
at, 288.
has no longer the importance attached to it in
pre-anaesthetic surgery, 2809.
VOLUME II 587
Urethra, healthy: bacteria cannot grow in mucus
of, 288.
Urethral mucous membrane :
from septic organisms, 237.
Urine: in flasks with bent necks, exposed to air,
no putrefaction in, 55.
Urine, boiled: development of organisms in, when
exposed to air in wineglass, 56.
mere raising of temperature to boiling point
insufficient to destroy germs, 58.
how particles from air are arrested in flasks with
bent necks, 58, 173.
experiment on putrefaction of, 173.
remains unaltered in flasks with bent necks for
nearly four years though exposed to atmo-
spheric gases, 174.
cause of putrefaction in, 486, 487, 488.
Urine, uncontaminated : addition of drop of water
to, causes bacteric development,
when healthy, free
27 ia
Vaccination: confers less permanent protection
than small-pox, 505.
small-pox modified by, 505.
should be completed by revaccination, 505.
use of calf lymph with antiseptic precautions
should be encouraged by government, 506.
“conscientious objections ’ would then cease to
have any rational basis, 506.
administration of regulations should be trans-
ferred to competent sanitary authorities, 506.
‘Vaccins ’: for protecting animals against anthrax
(Pasteur), 504.
Varicose veins. See Veins.
Variolae vaccinae: correctness of view implied in
that expression endorsed by Pasteur, 504.
Vascularization of blood-clot: under antiseptic
treatment, 153.
Vaso-motor function:
530. ee
Vein, bleeding: method of stitching with catgut
threaded through coats, 272, 274.
Veins, varicose: bleeding stopped by antiseptic
removal of mass and ligature, 273.
progress of case, 274.
Verduin (Amsterdam) method of amputation by
single flap, 383, 384.
Vermale: method of amputation with two flaps,
384.
Vertebrae, caries of.
Vibrio : cholera, 503-
Vibrios: in abscess in vicinity of colon, 42 (foof-
note).
chief agents in putrefaction, 47.
their quickening of motion in fluid, 47.
in putrefying pus, 482.
spring from similar organisms, 482.
Vinous fermentation. See Fermentation.
Virchow: reference to his ‘ Cellular Pathology ’
footnote, 150.
his teaching on the proliferation of cells, 542.
Virus, attenuation of, in fowl cholera supplies
explanation of difference of virulence of
disease in different epidemics, 504.
application of principle in production of im-
munity against anthrax, 504.
analogy with vaccination against anthrax, 504.
Virus of hydrophobia : reinforcement of, in rabbits,
507.
chemical poison in, 507.
experiments on, in frog,
See Caries.
in
Qq
588
Volkmann (Halle): demonstration of effects of
antiseptic treatment, 249, 250.
no death from compound fracture in his clinique
since introduction of antiseptic method, 250.
case of anthrax resulting from use of catgut
ligature made from intestine of sheep that
had died from the disease, 341 (footnote).
downward growth of femur when knee long
bent, 442.
Vomiting, obstinate: after free application of
undiluted carbolic acid to large wound, 84.
Waller, A: his observation that galvanic stimula-
tion of distal end of divided sympathetic in
neck causes pallor of ear, 529.
War: antiseptic treatment of wounded soldiers in,
161.
Water: septic ferments in, 225, 226.
bacteria in, 226, 277.
number and variety of micro-organisms in, 277.
addition of one-hundredth of a minim of, to
uncontaminated milk causes bacteric develop-
ment, 277.
no putrefaction caused by addition of, to
coagulated blood from ox, 278; this con-
firmed by similar experiments on blood of
donkey and dog, 278.
no putrefaction caused by addition of, to serum,
278.
Water-dressing : action of blood-clot in, prevent-
ing putrefaction under, 287.
Liston’s preference for, 517.
invariably putrid within twenty-four hours, 517.
Watson, Eben: compound fracture of tibia
treated with pure carbolic acid, 27.
Watson, Patrick Heron: his employment of soap
plaster mixed with carbolic acid, 71; deliga-
tion of circumferential vessels before removal
of goitre, 102.
Watts : his statement (in Dictionary of. Chemistry)
that mercuric albuminate is obtained by pre-
cipitating corrosive sublimate with albuminate
of sodium, 299.
Web, cicatricial: advantages of antiseptic treat-
ment after division of, 201.
Webbed fingers: coalescence of granulations after
division counteracted by elastic traction with
india-rubber, 201.
Wells, T. Spencer: successful ovariotomies in pre-
antiseptic period, 275.
White: first use of horse hair drain, 444.
Wiseman, Richard: method of amputation, 381
(and footnote) ; the same as that of Archigenes,
381.
knew of, but did not use ligature, 381 (footnote).
recommends ‘royal styptic’, 381.
actual cautery necessary in ‘ the heat of fight’,
381.
Wittich, v.: changes of colour in green tree-frog
due to pigmentary variation, 524.
Wood wool. See Sublimate.
WOUNDS: ADDRESS ON THE TREATMENT
OF (1881), 275.
Wound: protected from stimulation and con-
sequent granulation may at later period be
subjected to stimulation by antiseptic, with
suppuration, 82.
washing of, with corrosive sublimate solution,
and irrigation during stitching, 336.
INDEX TO VOLUME II
Wound (continued):
doubts as to necessity of washing or irrigation,
336.
washing of, with carbolic acid after operation,
354; this final washing omitted later, 355
(footnote).
Wound, external: healing by ‘first intention’
formerly exceptional, 496.
healing by granulation, 496.
Wound, operation: not irrigated but washed with
sublimate solution, 343; success of this plan,
343-
dressing of, in absence of chemical antiseptics,
355.
Wound of palm: fetid and suppurating, treated by
injection of saturated watery solution of car-
bolic acid, 83.
Wound, penetrating: of thorax and abdomen,
Ol.
of lung and abdomen, treated antiseptically with
success, 61.
Wound, recent: tissues of, incapable of forming pus
whether stimulated by nervous (inflammatory)
excitement, or chemical irritants (products of
putrefaction or pungent antiseptics), 82.
suppurates only when granulations form, 82.
Wounded soldiers in war: method of antiseptic
treatment applicable to, 161 ; details of, 161 ;
rationale of, 162.
WOUNDS, ADDRESS ON THE TREATMENT
OF (1881), 275.
Wounds: local inflammation and general fever
caused by decomposing discharges in, 2.
sloughing in, 2.
suppuration in, 2, 37; due to decomposition
caused by influence of atmosphere, 37.
method of antiseptic dressing of, 38.
use of drainage tubes in, 216, 217, 218, 221 ;
illustrative cases, 218.
advantages of drainage tubes in later stages of
treatment of, 221.
danger from action of putrefactive products on,
avoided by antiseptic measures, 241.
erysipelas may occur when all fermentative
agency has been excluded, 241 (footnote).
dry dressing of, 290 (footnote).
washing of, reversion to carbolic acid for, 344.
antiseptic management of, 349.
horsehair as a drain for, 414.
process of healing in, 448, 449, 450, 497.
process of healing in, as seen under antiseptic
treatment, 497.
various complications of, have each special
microbe, 501.
Syme’s method of dressing, 517.
suppuration formerly almost invariable, 518.
Wounds, abdominal: peculiar characters of, 275.
plasma from cut surface effused into large cavity
where it is readily absorbed by serous mem-
brane, 275, 276; hence no opportunity for
putrefaction, 277.
absence of tension in, 277.
high vital power of peritoneum, 277.
Wounds, contused: suppuration caused by in-
fluence of atmosphere on tissue destroyed by
injury, 37.
antiseptic treatment of, 44, 48.
of foot, treated antiseptically, 68.
treated with block-tin and antiseptic lac, 79.
INDEX TO VOLUME II
Wounds, contused (continued) :
of head or foot, benefits of antiseptic method
conspicuous in treatment of, 131.
every isolated slough in vicinity of, must be
dressed antiseptically, 152.
with smashing of hand or foot, healed by means
of antiseptic dressing and drainage tubes, 248.
must be purified by powerful antiseptic means,
8.
Woends deep: successfully treated by antiseptic
dressing and drainage tube (Saxtorph), 248.
Wounds, incised: carbolic acid not suitable for
application to, owing to caustic properties,
341.
Wounds, operation: grosser forms of septic mis-
chief must be excluded from, 351.
Wounds of scalp: antiseptic treatment of, 1309,
140, I5I.
details of dressing, 139, 140.
Wounds, simple incised: antiseptic treatment of,
44.
Wrist, disease of: treated by antiseptic incision,
194; case treated by partial excision under
spray, 195.
antiseptic excision of, for caries, 199.
formation of new joint after, 200.
caries of, treated by early free incision practised
antiseptically, 200.
disease of, treated by actual cautery (Syme), 375,
376.
excision of, for caries, 417.
See also Caries.
Wrist, excision of: cases illustrating author’s
method of operating and its results, 419, 420,
421, 422, 423, 424, 425.
improvements in method, 425, 426, 438, 439.
detailed description of the method, 427, 428, 429,
430.
after-treatment of, 431, 432, 433, 434.
passive movements, 432, 433.
persistence of sinuses after operation, 435, 436,
heapiel gangrene causing return of disease, 435,
436, 437, 438, 439.
death after, 439, 440.
review of results, 440.
mode in which new joint is formed, 438.
pyaemia after, 439, 440.
Wrist-joint, disease of: cured by actual cautery
(Syme), 375, 376.
amputation at, 398, 399.
589
X-rays. See Rontgen.
Yeast plant: produces vinous fermentation in
saccharine solution, 47.
discovered by Cagniard-Latour in 1836, 479.
and independently in following year by Schwann,
479-
Yersin: his experiments on agents having germi-
cidal action on tubercle bacillus, 351.
Young, James (Plymouth): his description (in
Currus Triumphalis e Terebintho, 1679) of a
tourniquet invented by himself, 381.
method of amputation with single flap (1678),
383 ; suggested to him by C. Lowdham, 383.
Ziegler: experiments showing that leucocytes
penetrate very thin spaces between plates of
glass or other chemically inert foreign body,
inserted among tissues, 334. :
Zinc chloride: use of, in surgical operations and
wounds introduced by Campbell de Morgan, 51,
214 (footnote).
antiseptic effects of, 51.
in treatment of compound iracture, 52.
inferior to carbolic acid except in cases when
application must be made once for all at time
of operation, 53.
valuable after removal of portions of maxillary
bone, 53
used with advantage by author after removal
of tongue, 53.
injection of, to sinuses in amputations and
excisions, 131 (footnote), 214.
use of, as antiseptic in treatment of sinuses,
214.
accidents from injection of, into sinuses at begin-
ning of operation, 214.
its peculiar advantages as an antiseptic, 214.
failure of, owing to antiseptic not penetrating
into recesses, 251.
smarting caused by, 243 (footnote).
ZINC CYANIDE AND MERCURY, FURTHER
OBSERVATIONS ON (1889), 324.
Zinc cyanide: found to have antiseptic properties,
320, 321; but not so powerful as double
cyanide of mercury, 321.
experiments on antiseptic power of, 321, 322.
Zinc cyanide gauze. See Gauze.
Zinco-cyanide of mercury. See Mercury.
Zinco-cyanide of mercury gauze. See Gauze.
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